Basic Information
| Provider Information | |||||||||
| NPI: | 1578566774 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TISDALL | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 100519 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303840519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882086228 | ||||||||
| FaxNumber: | 6037781602 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 HAMPTON RD | ||||||||
| Address2: | UNIT 208 | ||||||||
| City: | EXETER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038334849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037788522 | ||||||||
| FaxNumber: | 6037781602 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 06/03/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 7703 | NH | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 57504 | MA | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 3021904 | 05 | MA | MEDICAID | 0105363Y0HN01 | 01 | NH | BCBS | OTHER | 30002058 | 05 | NH | MEDICAID | 57504 | 01 | MA | MEDICAL LICENSURE | OTHER | 7703 | 01 | NH | MEDICAL LICENSURE | OTHER | R01137 | 01 | MA | BCBS | OTHER |