Provider Demographics
NPI:1952410177
Name:TISDALE, GEORGE G (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:G
Last Name:TISDALE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:425 MONTGOMERY HWY
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35216-1805
Mailing Address - Country:US
Mailing Address - Phone:205-822-5559
Mailing Address - Fax:205-822-5559
Practice Address - Street 1:425 MONTGOMERY HWY
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35216-1805
Practice Address - Country:US
Practice Address - Phone:205-822-5559
Practice Address - Fax:205-822-5559
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL8522207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALC71906Medicare UPIN