MEDICARE: PHILIP A TISDALL M.D.

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	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	7703	NH
2	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	57504	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0105363Y0HN01	OTHER	NH	BCBS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	57504	OTHER	MA	MEDICAL LICENSURE
5	7703	OTHER	NH	MEDICAL LICENSURE
6	R01137	OTHER	MA	BCBS

General Provider Information

NPI Number	:	1578566774
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILIP A TISDALL M.D.

Provider Business Mailing Address
First Line	:	PO BOX 100519
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30384-0519
Country	:	US
Telephone Number	:	888-208-6228
Fax Number	:	603-778-1602

Provider Business Practice Location Address
First Line	:	1 HAMPTON RD
Second Line	:	UNIT 208
City	:	EXETER
State	:	NH
Zip	:	03833-4849
Country	:	US
Telephone Number	:	603-778-8522
Fax Number	:	603-778-1602

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

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	06/03/2008

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Directions to “ PHILIP A TISDALL M.D.” Practice Location

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