Healthcare Provider Details

I. General information

NPI: 1780098756
Provider Name (Legal Business Name): NATHAN TIDWELL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2014
Last Update Date: 10/27/2025
Certification Date: 10/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 BLUFF AVE # 29841
NORTH AUGUSTA SC
29841-3862
US

IV. Provider business mailing address

150 BLUFF AVE # 29841
NORTH AUGUSTA SC
29841-3862
US

V. Phone/Fax

Practice location:
  • Phone: 803-624-1313
  • Fax: 803-426-9236
Mailing address:
  • Phone: 803-624-1313
  • Fax: 803-426-9236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number75019
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number075019
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: