Provider Demographics
NPI:1033141031
Name:TIDWELL, SERENA DAVIS (MD)
Entity Type:Individual
Prefix:DR
First Name:SERENA
Middle Name:DAVIS
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1538 13TH AVE
Mailing Address - Street 2:SUITE C 200
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-1956
Mailing Address - Country:US
Mailing Address - Phone:706-320-2547
Mailing Address - Fax:706-320-2549
Practice Address - Street 1:1538 13TH AVE
Practice Address - Street 2:SUITE C 200
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1956
Practice Address - Country:US
Practice Address - Phone:706-320-2547
Practice Address - Fax:706-320-2549
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051192174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH58549Medicare UPIN