Provider Demographics
NPI:1114032323
Name:TIDWELL, CHRISTOPHER K (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:K
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1538 13TH AVENUE
Mailing Address - Street 2:SUITE C100
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-1595
Mailing Address - Country:US
Mailing Address - Phone:706-494-7000
Mailing Address - Fax:706-494-7011
Practice Address - Street 1:1538 13TH AVE
Practice Address - Street 2:C100
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1595
Practice Address - Country:US
Practice Address - Phone:706-494-7000
Practice Address - Fax:706-494-7011
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2016-04-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA054351207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA551575810AMedicaid
GAI10341Medicare UPIN
GA11SCCWKMedicare ID - Type Unspecified