Healthcare Provider Details

I. General information

NPI: 1679962641
Provider Name (Legal Business Name): DR. KAREN A. TIDMORE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2015
Last Update Date: 01/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1811 SHARP SPRINGS RD
WINCHESTER TN
37398-4659
US

IV. Provider business mailing address

1811 SHARP SPRINGS RD
WINCHESTER TN
37398-4659
US

V. Phone/Fax

Practice location:
  • Phone: 931-967-7716
  • Fax:
Mailing address:
  • Phone: 931-967-7716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO 0000000400
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN0000015232
License Number StateTN

VIII. Authorized Official

Name: KAREN TIDMORE
Title or Position: FAMILY PRACTICE
Credential:
Phone: 931-967-7716