Healthcare Provider Details

I. General information

NPI: 1033672837
Provider Name (Legal Business Name): CODY D. TIDWELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 DELAWARE ST SE
MINNEAPOLIS MN
55455-0341
US

IV. Provider business mailing address

420 DELAWARE ST SE
MINNEAPOLIS MN
55455-0341
US

V. Phone/Fax

Practice location:
  • Phone: 612-625-4116
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number13284677-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number13284677-1205
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number77909
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: