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General NPI Number Information
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NPI Number | 1093086563
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Entity Type | Organization
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Legal Business Name | PAT T. TIDWELL MD PA
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Dates
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Enumeration Date | 01/16/2012
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Last Update Date | 12/12/2018
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Provider Practice Location Address
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Address Line | 4554 HIGHWAY 20 EAST
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City | NICEVILLE
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State | FL
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Zip | 32578
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Country | US
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Telephone | 850-678-6735
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Fax | 850-678-8078
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Provider Business Mailing Address
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Address Line | 4554 HIGHWAY 20 EAST
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City | NICEVILLE
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State | FL
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Zip | 32578
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Country | US
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Telephone | 850-678-6735
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Fax | 850-678-8078
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. PAT THOMAS TIDWELL SR.
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Credential | M.D.
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Telephone | 850-678-6735
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | ME30890
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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