Provider Demographics
NPI:1043070543
Name:TIDWELL, ELI PEARSON
Entity Type:Individual
Prefix:
First Name:ELI
Middle Name:PEARSON
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5333 MCAULEY DR RM 4001
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-1099
Mailing Address - Country:US
Mailing Address - Phone:734-712-3980
Mailing Address - Fax:
Practice Address - Street 1:5333 MCAULEY DR
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1014
Practice Address - Country:US
Practice Address - Phone:734-712-3980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program