Provider Demographics
NPI:1326149683
Name:TIDWELL, STEPHEN CRAIG (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:CRAIG
Last Name:TIDWELL
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 1:1105 BURLEYSON RD
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-3017
Mailing Address - Country:US
Mailing Address - Phone:706-278-4640
Mailing Address - Fax:706-275-6599
Practice Address - Street 1:1105 BURLEYSON RD
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-3017
Practice Address - Country:US
Practice Address - Phone:706-278-4640
Practice Address - Fax:706-275-6599
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046332207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00812743AMedicaid
GAH51749Medicare UPIN
GA16BDSVMMedicare ID - Type UnspecifiedMEDICARE