Basic Information
| Provider Information | |||||||||
| NPI: | 1316920416 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TISDALE | ||||||||
| FirstName: | DOUGLAS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 808 | ||||||||
| Address2: | |||||||||
| City: | NASHUA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030610808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035785054 | ||||||||
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| Practice Location | |||||||||
| Address1: | 41 MALL RD LAHEY HOSPITAL AND MEDICAL CENTER | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018053648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817448400 | ||||||||
| FaxNumber: | 7817445245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 08/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 13131 | NH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | 153488 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 3074335 | 05 | NH | MEDICAID |