Provider Demographics
NPI:1740200765
Name:TIDWELL, NICHELL (MD)
Entity Type:Individual
Prefix:
First Name:NICHELL
Middle Name:
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NICHELL
Other - Middle Name:
Other - Last Name:TIDWELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:225 E CHICAGO AVE # 152
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2991
Mailing Address - Country:US
Mailing Address - Phone:800-543-7362
Mailing Address - Fax:
Practice Address - Street 1:225 E CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2991
Practice Address - Country:US
Practice Address - Phone:800-543-7362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036086376207P00000X, 207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036086376Medicaid
ILK38060Medicare PIN