Healthcare Provider Details

I. General information

NPI: 1215001045
Provider Name (Legal Business Name): BERNARD A TISDALE MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26079 LEE HIGHWAY
ABINGDON VA
24211
US

IV. Provider business mailing address

1020A BOAL AVE
BOALSBURG PA
16827-1509
US

V. Phone/Fax

Practice location:
  • Phone: 276-739-2222
  • Fax:
Mailing address:
  • Phone: 814-237-8627
  • Fax: 814-238-0083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number StateVA

VIII. Authorized Official

Name: BERNARD T TISDALE
Title or Position: OWNER
Credential: MD
Phone: 804-254-5100