Provider Demographics
NPI:1083663280
Name:LIDSKY, NATHAN (MD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:LIDSKY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1481 HOLLIS RDG
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-1522
Mailing Address - Country:US
Mailing Address - Phone:479-876-2121
Mailing Address - Fax:
Practice Address - Street 1:1481 HOLLIS RDG
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-1522
Practice Address - Country:US
Practice Address - Phone:847-987-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN60432207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360785681Medicaid
IL0360785682Medicaid
ILP00249292OtherRAILROAD MEDICARE
IL036078568OtherBCBS
ILP00249292OtherRAILROAD MEDICARE
IL0360785682Medicaid