Provider Demographics
NPI:1588663686
Name:TIDMAN, RAYMOND EUGENE (MD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:EUGENE
Last Name:TIDMAN
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 1:101 RIVERSTONE VIS
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-6648
Mailing Address - Country:US
Mailing Address - Phone:706-632-4400
Mailing Address - Fax:706-632-4404
Practice Address - Street 1:101 RIVERSTONE VIS
Practice Address - Street 2:SUITE 205
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-6648
Practice Address - Country:US
Practice Address - Phone:706-632-4400
Practice Address - Fax:706-632-4404
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032826207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA428836OtherBC/BS
08BDGDX02Medicare ID - Type Unspecified
GA428836OtherBC/BS