Provider Demographics
NPI:1689643637
Name:FIDLER, PHILIP E (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:E
Last Name:FIDLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12187
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30914-2187
Mailing Address - Country:US
Mailing Address - Phone:706-863-9595
Mailing Address - Fax:706-868-8375
Practice Address - Street 1:1600 COIT RD STE 305
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-6172
Practice Address - Country:US
Practice Address - Phone:706-863-9595
Practice Address - Fax:706-868-8375
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR8186208600000X, 2086S0102X
VA01012730722086S0102X
WY10838A2086S0102X
FLME1526062086S0102X
COCDRH.00550392086S0102X
IDMC-04322086S0102X
GA739602086S0102X
MS275722086S0102X
NV195242086S0102X
TNMD00000642042086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTH16558Medicare UPIN
CT020001462Medicare ID - Type Unspecified
CT001378703Medicaid