Provider Demographics
NPI:1659680114
Name:TIDWELL, PHILLIP D
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:D
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2148 AZTEC DR
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-1841
Mailing Address - Country:US
Mailing Address - Phone:731-589-6156
Mailing Address - Fax:615-467-8971
Practice Address - Street 1:2148 AZTEC DR
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-1841
Practice Address - Country:US
Practice Address - Phone:731-589-6156
Practice Address - Fax:615-467-8971
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-01
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRRT00000003952279P1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2279P1004XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredPulmonary Diagnostics