Healthcare Provider Details

I. General information

NPI: 1215030416
Provider Name (Legal Business Name): BERNARD A. TISDALE, M.D., P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 W MARSHALL ST
RICHMOND VA
23220-3835
US

IV. Provider business mailing address

1109 W MARSHALL ST
RICHMOND VA
23220-3835
US

V. Phone/Fax

Practice location:
  • Phone: 804-257-7337
  • Fax:
Mailing address:
  • Phone: 804-257-7337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateVA

VIII. Authorized Official

Name: DR. BERNARD A TISDALE
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 804-257-7337