Active NPI
Detra Michelle Tisdale, M.D.
- Internal Medicine Physician
- Cordova, TN
National Provider Identifier
1730273079
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Internal Medicine Physician
- License
- 46435
- Practice address
- 1144 N Houston Levee Rd
Suite 102
Cordova, TN 38018-7145 - Phone
- (901) 382-2044
- NPI assigned
- Oct 3, 2006
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 3
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Internal Medicine Physician | 207R00000X | 053713 | GA | |
| Internal Medicine Physician | 207R00000X | MD202661 | LA | |
| Internal Medicine Physician | 207R00000X | 46435 | TN | Primary |
Addresses
Primary practice location
1144 N Houston Levee Rd
Suite 102
Cordova, TN 38018-7145
Mailing address
1144 N Houston Levee Rd
Suite 102
Cordova, TN 38018-7145
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 06837219 | Medicaid | MS | |
| 1369047 | Medicaid | LA |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| MD202661 | LA | MD | Internal Medicine Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Saint Francis Physician Network, LLC | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Family Medicine Physician
- Covington, TN
- NPI 1295258002
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1159833600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1291593600000",
"number": "1730273079",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1144 N HOUSTON LEVEE RD",
"address_2": "SUITE 102",
"city": "CORDOVA",
"state": "TN",
"postal_code": "380187145"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1144 N HOUSTON LEVEE RD",
"address_2": "SUITE 102",
"city": "CORDOVA",
"state": "TN",
"postal_code": "380187145",
"telephone_number": "901-382-2044"
}
],
"practiceLocations": [],
"basic": {
"last_name": "TISDALE",
"first_name": "DETRA",
"middle_name": "MICHELLE",
"name_prefix": "Dr.",
"credential": "M.D.",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-10-03",
"last_updated": "2010-12-06",
"status": "A"
},
"taxonomies": [
{
"code": "207R00000X",
"taxonomy_group": "",
"desc": "Internal Medicine",
"state": "GA",
"license": "053713",
"primary": false
},
{
"code": "207R00000X",
"taxonomy_group": "",
"desc": "Internal Medicine",
"state": "LA",
"license": "MD202661",
"primary": false
},
{
"code": "207R00000X",
"taxonomy_group": "",
"desc": "Internal Medicine",
"state": "TN",
"license": "46435",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "06837219",
"state": "MS"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "1369047",
"state": "LA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Cordova, TN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 6, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.