Provider Demographics
NPI:1366589608
Name:RICHARD H TIDWELL MD PLLC
Entity type:Organization
Organization Name:RICHARD H TIDWELL MD PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:H
Authorized Official - Last Name:TIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-253-2550
Mailing Address - Street 1:PO BOX 987
Mailing Address - Street 2:
Mailing Address - City:JAY
Mailing Address - State:OK
Mailing Address - Zip Code:74346-0987
Mailing Address - Country:US
Mailing Address - Phone:918-253-2550
Mailing Address - Fax:918-253-2559
Practice Address - Street 1:2485 N MAIN STREET
Practice Address - Street 2:
Practice Address - City:JAY
Practice Address - State:OK
Practice Address - Zip Code:74346-0987
Practice Address - Country:US
Practice Address - Phone:918-253-2550
Practice Address - Fax:918-253-2559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18708207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK442760537004OtherBLUE CROSS BLUE SHIELD
OK=========OtherTAX ID
OK=========OtherTRICARE
OK442760537004OtherBLUE CROSS BLUE SHIELD
OKP00179118Medicare PIN