Provider Demographics
NPI:1578776670
Name:CHERYL C. TIDBALL DO PC
Entity Type:Organization
Organization Name:CHERYL C. TIDBALL DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:C
Authorized Official - Last Name:TIDBALL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:503-489-0663
Mailing Address - Street 1:1217 NE BURNSIDE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-6722
Mailing Address - Country:US
Mailing Address - Phone:503-489-0663
Mailing Address - Fax:503-666-5644
Practice Address - Street 1:1217 NE BURNSIDE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-6722
Practice Address - Country:US
Practice Address - Phone:503-489-0663
Practice Address - Fax:503-666-5644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO19432208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR203778Medicaid
ORR114758Medicare ID - Type Unspecified
ORG05120Medicare UPIN