MEDICARE: MARQUETTE TIDMORE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374U00000X	Home Health Aide

General Provider Information

NPI Number	:	1528635430
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARQUETTE TIDMORE

Provider Business Mailing Address
First Line	:	9904 AETNA RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44105-2248
Country	:	US
Telephone Number	:	216-345-0990
Fax Number	:

Provider Business Practice Location Address
First Line	:	9904 AETNA RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44105-2248
Country	:	US
Telephone Number	:	216-345-0990
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2021
Last Update Date	:	06/09/2021

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Directions to “ MARQUETTE TIDMORE ” Practice Location

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