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General NPI Number Information
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NPI Number | 1932327418
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Entity Type | Individual
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Provider Name | JON MARC TIDBALL M.P.T.
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Gender | Male
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Dates
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Enumeration Date | 04/23/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 551 YMCA PL
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City | GAHANNA
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State | OH
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Zip | 43230-6851
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Country | US
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Telephone | 614-293-7600
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Fax | 614-293-7540
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Provider Business Mailing Address
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Address Line | 1173 WIMBELDON BLVD
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City | COLUMBUS
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State | OH
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Zip | 43228-9327
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Country | US
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Telephone | 614-946-1669
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Fax | 614-293-7540
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 11384
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License Number State | OH
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