Provider Demographics
NPI:1578566774
Name:TISDALL, PHILIP A (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:A
Last Name:TISDALL
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:PO BOX 100519
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-0519
Mailing Address - Country:US
Mailing Address - Phone:888-208-6228
Mailing Address - Fax:603-778-1602
Practice Address - Street 1:1 HAMPTON RD
Practice Address - Street 2:UNIT 208
Practice Address - City:EXETER
Practice Address - State:NH
Practice Address - Zip Code:03833-4849
Practice Address - Country:US
Practice Address - Phone:603-778-8522
Practice Address - Fax:603-778-1602
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH7703207ZP0102X
MA57504207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3021904Medicaid
NH0105363Y0HN01OtherBCBS
NH30002058Medicaid
MA57504OtherMEDICAL LICENSURE
NH7703OtherMEDICAL LICENSURE
MAR01137OtherBCBS
NHNH9466Medicare Oscar/Certification
NH0105363Y0HN01OtherBCBS
NHEX3735Medicare Oscar/Certification
MA57504OtherMEDICAL LICENSURE
MA3021904Medicaid