Provider Demographics
NPI:1912381245
Name:TISDALE, JEREMY (ATC, EMT-IV)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:TISDALE
Suffix:
Gender:M
Credentials:ATC, EMT-IV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 21ST AVE S
Mailing Address - Street 2:MEDICAL CENTER EAST SOUTH TOWER SUITE 3200
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37232-0014
Mailing Address - Country:US
Mailing Address - Phone:615-460-8041
Mailing Address - Fax:
Practice Address - Street 1:1900 BELMONT BLVD
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37212-3758
Practice Address - Country:US
Practice Address - Phone:615-460-8041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-16
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN30732146N00000X
TN16802255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic