1578566774 NPI number — PHILIP A TISDALL M.D.

Table of content: PHILIP A TISDALL M.D. (NPI 1578566774)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578566774 NPI number — PHILIP A TISDALL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TISDALL
Provider First Name:
PHILIP
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578566774
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 100519
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30384-0519
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-208-6228
Provider Business Mailing Address Fax Number:
603-778-1602

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 HAMPTON RD
Provider Second Line Business Practice Location Address:
UNIT 208
Provider Business Practice Location Address City Name:
EXETER
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03833-4849
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-778-8522
Provider Business Practice Location Address Fax Number:
603-778-1602
Provider Enumeration Date:
05/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X , with the licence number:  7703 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207ZP0102X , with the licence number: 57504 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3021904 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0105363Y0HN01 . This is a "BCBS" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 30002058 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 57504 . This is a "MEDICAL LICENSURE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 7703 . This is a "MEDICAL LICENSURE" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: R01137 . This is a "BCBS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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