Provider Demographics
NPI:1689759581
Name:SERENA D. TIDWELL, M.D., P.C.
Entity Type:Organization
Organization Name:SERENA D. TIDWELL, M.D., P.C.
Other - Org Name:MIDTOWN OB GYN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SERENA
Authorized Official - Middle Name:DAVIS
Authorized Official - Last Name:TIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-320-2547
Mailing Address - Street 1:1538 13TH AVE
Mailing Address - Street 2:SUITE C200
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-1956
Mailing Address - Country:US
Mailing Address - Phone:706-320-2547
Mailing Address - Fax:706-320-2549
Practice Address - Street 1:1538 13TH AVE
Practice Address - Street 2:SUITE C200
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1956
Practice Address - Country:US
Practice Address - Phone:706-320-2547
Practice Address - Fax:706-320-2549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051192305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH58549Medicare UPIN
GRP4813Medicare ID - Type Unspecified