Provider Demographics
NPI:1942572516
Name:BIDWELL, TRACY
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:BIDWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:284 S RIDGE RD W
Mailing Address - Street 2:
Mailing Address - City:CONNEAUT
Mailing Address - State:OH
Mailing Address - Zip Code:44030-9709
Mailing Address - Country:US
Mailing Address - Phone:440-813-5131
Mailing Address - Fax:
Practice Address - Street 1:284 S. RIDGE RD W
Practice Address - Street 2:
Practice Address - City:CONNEAUT
Practice Address - State:OH
Practice Address - Zip Code:44030
Practice Address - Country:US
Practice Address - Phone:440-813-5131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0126454146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic