1366589608 NPI number — RICHARD H TIDWELL MD PLLC

Table of content: (NPI 1366589608)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366589608 NPI number — RICHARD H TIDWELL MD PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RICHARD H TIDWELL MD PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1366589608
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 987
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JAY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74346-0987
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-253-2550
Provider Business Mailing Address Fax Number:
918-253-2559

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2485 N MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JAY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74346-0987
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-253-2550
Provider Business Practice Location Address Fax Number:
918-253-2559
Provider Enumeration Date:
01/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TIDWELL
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
H
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
918-253-2550

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  18708 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 442760537004 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com