1598085243 NPI number — WILLIAM A. TISDALL, M.D., P.A.

Table of content: (NPI 1598085243)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598085243 NPI number — WILLIAM A. TISDALL, M.D., P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLIAM A. TISDALL, M.D., P.A.
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:
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:
1598085243
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/05/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1919 ROGERS RD
Provider Second Line Business Mailing Address:
SUITE 204
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78251-4614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-541-0700
Provider Business Mailing Address Fax Number:
210-514-6868

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1919 ROGERS RD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78251-4614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-541-0700
Provider Business Practice Location Address Fax Number:
210-514-6868
Provider Enumeration Date:
06/04/2010

Additional Information

Authorized Official

Authorized Official Last Name:
TISDALL
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
ALEC
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
210-541-0700

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 217091201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0039TQ . This is a "BLUE CROSS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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