Provider Demographics
NPI:1093086563
Name:PAT T. TIDWELL MD PA
Entity Type:Organization
Organization Name:PAT T. TIDWELL MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PAT
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:TIDWELL
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:850-678-6735
Mailing Address - Street 1:4554 HIGHWAY 20 EAST
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578
Mailing Address - Country:US
Mailing Address - Phone:850-678-6735
Mailing Address - Fax:850-678-8078
Practice Address - Street 1:4554 HIGHWAY 20 EAST
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578
Practice Address - Country:US
Practice Address - Phone:850-678-6735
Practice Address - Fax:850-678-8078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-16
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
FLME30890261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD54957Medicare UPIN