Provider Demographics
NPI:1770659609
Name:JOHN SCOTT TIDBALL, MD, PC
Entity Type:Organization
Organization Name:JOHN SCOTT TIDBALL, MD, PC
Other - Org Name:WILDEWOOD MEDICAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:TIDBALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-737-7833
Mailing Address - Street 1:23415 THREE NOTCH RD
Mailing Address - Street 2:STE 2054 WILDEWOOD CTR
Mailing Address - City:CALIFORNIA
Mailing Address - State:MD
Mailing Address - Zip Code:20619-4017
Mailing Address - Country:US
Mailing Address - Phone:301-737-7833
Mailing Address - Fax:301-737-4865
Practice Address - Street 1:23415 THREE NOTCH RD
Practice Address - Street 2:STE 2054 WILDEWOOD CTR
Practice Address - City:CALIFORNIA
Practice Address - State:MD
Practice Address - Zip Code:20619-4017
Practice Address - Country:US
Practice Address - Phone:301-737-7833
Practice Address - Fax:301-737-4865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-24
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD52196207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD138950500Medicaid
MDG61586Medicare UPIN