Provider Demographics
NPI:1548239080
Name:TISDEL, CHRISTOPHER L (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:L
Last Name:TISDEL
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 1:44555 WOODWARD AVE STE 406
Mailing Address - Street 2:SUITE 407
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-5036
Mailing Address - Country:US
Mailing Address - Phone:248-334-0524
Mailing Address - Fax:
Practice Address - Street 1:6847 N CHESTNUT ST STE 105
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-3929
Practice Address - Country:US
Practice Address - Phone:330-297-6030
Practice Address - Fax:330-297-4919
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI081413174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0630027OtherBLUE CROSS/BLUE SHIELD
MI4513256Medicaid
MI4513256Medicaid
MIF68212Medicare UPIN