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General NPI Number Information
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NPI Number | 1942837588
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Entity Type | Individual
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Provider Name | LUCAS TIDWELL MD
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Gender | Male
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Dates
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Enumeration Date | 03/24/2020
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Last Update Date | 07/08/2025
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Provider Practice Location Address
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Address Line | 22250 PROVIDENCE DR STE 206
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City | SOUTHFIELD
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State | MI
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Zip | 48075-6210
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Country | US
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Telephone | 248-662-4333
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Fax |
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Provider Business Mailing Address
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Address Line | 22250 PROVIDENCE DR STE 206
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City | SOUTHFIELD
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State | MI
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Zip | 48075-6210
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Country | US
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Telephone | 248-662-4333
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Fax |
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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 | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 4301514131
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License Number State | MI
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