Basic Information
Provider Information | |||||||||
NPI: | 1558774950 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LIND | ||||||||
FirstName: | KERRIE | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | TIDWELL | ||||||||
OtherFirstName: | KERRIE | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 7503 SURRATTS RD | ||||||||
Address2: |   | ||||||||
City: | CLINTON | ||||||||
State: | MD | ||||||||
PostalCode: | 207353358 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3018688000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 7503 SURRATTS RD | ||||||||
Address2: |   | ||||||||
City: | CLINTON | ||||||||
State: | MD | ||||||||
PostalCode: | 207353358 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3018688000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/04/2014 | ||||||||
LastUpdateDate: | 07/08/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207P00000X | D0079851 | MD | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | 0101257908 | VA | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
No ID Information.