MEDICARE: ANTONIA TIDWELL RDMS, RVT, RDCS, RTR

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	246XS1301X	Sonography Specialist/Technologist Cardiovascular	115198	TN
2	2471C3402X	Radiography Radiologic Technologist	310458	TN
3	2471S1302X	Sonography Radiologic Technologist	115198	TN
4	2471V0105X	Vascular Sonography Radiologic Technologist	115198	TN

General Provider Information

NPI Number	:	1548519739
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTONIA TIDWELL RDMS, RVT, RDCS, RTR

Provider Business Mailing Address
First Line	:	323 SAVANNAH RDG
Second Line	:
City	:	MURFREESBORO
State	:	TN
Zip	:	37127-8331
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	323 SAVANNAH RDG
Second Line	:
City	:	MURFREESBORO
State	:	TN
Zip	:	37127-8331
Country	:	US
Telephone Number	:	615-708-3179
Fax Number	:

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

Provider Enumeration Date	:	09/03/2012
Last Update Date	:	09/03/2012

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