Healthcare Provider Details

I. General information

NPI: 1659680114
Provider Name (Legal Business Name): PHILLIP D TIDWELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2010
Last Update Date: 06/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2148 AZTEC DR
DYERSBURG TN
38024-1841
US

IV. Provider business mailing address

2148 AZTEC DR
DYERSBURG TN
38024-1841
US

V. Phone/Fax

Practice location:
  • Phone: 731-589-6156
  • Fax: 615-467-8971
Mailing address:
  • Phone: 731-589-6156
  • Fax: 615-467-8971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2279P1004X
TaxonomyPulmonary Diagnostics Registered Respiratory Therapist
License NumberRRT0000000395
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: