Basic Information
| Provider Information | |||||||||
| NPI: | 1942427380 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TIDWELL | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | ELLIOTT | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23229 | ||||||||
| Address2: | |||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423043229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706881330 | ||||||||
| FaxNumber: | 2706881338 | ||||||||
| Practice Location | |||||||||
| Address1: | 2211 MAYFAIR DR STE 305 | ||||||||
| Address2: | |||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423014572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706883700 | ||||||||
| FaxNumber: | 2706883709 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2007 | ||||||||
| LastUpdateDate: | 07/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | 47992 | KY | N | Allopathic & Osteopathic Physicians | Plastic Surgery | 2086S0122X | 47992 | KY | Y | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
No ID Information.