MEDICARE: CATHERINE M TISDALL MD

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	207N00000X	Dermatology Physician	M5220	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00605100	OTHER	TX	MEDICARE RR
6	DG9652	OTHER	TX	MEDICARE RR GROUP PTAN
7	00203V	OTHER	TX	MEDICARE PTAN GROUP

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	8X5051	OTHER	TX	BCBS
3	M5220	OTHER	TX	LICENSE
4	207N00000X	OTHER	TX	TAXONOMONY
5	742935457	OTHER	TX	TAX ID

General Provider Information

NPI Number	:	1871556506
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CATHERINE M TISDALL MD

Provider Business Mailing Address
First Line	:	8431 FREDERICKSBURG RD
Second Line	:	#100
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-3392
Country	:	US
Telephone Number	:	210-615-7171
Fax Number	:	210-615-6793

Provider Business Practice Location Address
First Line	:	8431 FREDERICKSBURG RD
Second Line	:	#100
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-3392
Country	:	US
Telephone Number	:	210-615-7171
Fax Number	:	210-615-6793

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

Provider Enumeration Date	:	04/12/2006
Last Update Date	:	10/27/2009

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Directions to “ CATHERINE M TISDALL MD” Practice Location

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