MEDICARE: DR. DETRA MICHELLE TISDALE 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	207R00000X	Internal Medicine Physician	053713	GA
2	207R00000X	Internal Medicine Physician	MD202661	LA
3	207R00000X	Internal Medicine Physician	46435	TN

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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730273079
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DETRA MICHELLE TISDALE M.D.

Provider Business Mailing Address
First Line	:	1144 N HOUSTON LEVEE RD
Second Line	:	SUITE 102
City	:	CORDOVA
State	:	TN
Zip	:	38018-7145
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1144 N HOUSTON LEVEE RD
Second Line	:	SUITE 102
City	:	CORDOVA
State	:	TN
Zip	:	38018-7145
Country	:	US
Telephone Number	:	901-382-2044
Fax Number	:

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

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	12/06/2010

Similar Medicare Providers

1922435478 — LEADER PHYSICAL THERAPY LIMITED PARTNERSHIP
Practice Location Address:

1144 N HOUSTON LEVEE RD , SUITE 103
CORDOVA, TN
38018-7145

Practice Phone: 901-754-9610
Practice Fax: 901-754-4722

1447023882 — NATIONAL TRANSPORT, INC
Practice Location Address:

1144 N HOUSTON LEVEE RD STE 103
CORDOVA, TN
38018-7145

Practice Phone: 501-944-7074
Practice Fax:

1699631291 — DR. CENE HARRIS PH.D.
Practice Location Address:

593 ARBOR HOLLOW CIR APT 205
CORDOVA, TN
38018-3407

Practice Phone: 504-296-7779
Practice Fax:

1568328060 — KAREN THOMAS
Practice Location Address:

551 SANGA CIR E
CORDOVA, TN
38018-7646

Practice Phone: 901-326-3042
Practice Fax:

1174489561 — MS. JUSTICE BRIANA FIELDS RBT
Practice Location Address:

6902 AMBERLY GROVE CV
CORDOVA, TN
38018-5615

Practice Phone: 901-857-1053
Practice Fax:

1184276867 — DVANISHIA ALFORD
Practice Location Address:

8090 WALNUT RUN RD
CORDOVA, TN
38018-6362

Practice Phone: 901-509-8347
Practice Fax: 855-430-0596

Directions to “ DR. DETRA MICHELLE TISDALE M.D.” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2026 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.