1699011312 NPI number — TIDEWATER MEDICAL TRANSPORT, INC

Table of content: (NPI 1699011312)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699011312 NPI number — TIDEWATER MEDICAL TRANSPORT, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIDEWATER MEDICAL TRANSPORT, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
TIDEWATER MEDICAL TRANSPORT LLC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699011312
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/26/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2503 WOODROW ST
Provider Second Line Business Mailing Address:
SUITE 8
Provider Business Mailing Address City Name:
PORTSMOUTH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23707-2124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-399-0999
Provider Business Mailing Address Fax Number:
757-399-1999

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2503 WOODROW ST STE 8
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTSMOUTH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23707-2124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-399-0999
Provider Business Practice Location Address Fax Number:
757-399-1999
Provider Enumeration Date:
12/27/2012

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
DAWN
Authorized Official Title or Position:
PRESIDENT-OWNER
Authorized Official Telephone Number:
757-399-0999

Provider Taxonomy Codes

  • Taxonomy code: 341600000X , with the licence number:  0786425-9 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3416L0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0786425-9 . This is a "STATE CORPORATION COMMISSION" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 01333 . This is a "VIRGINIA OFFICE OF EMERGENCY MEDICAL SERVICES (VAOEMS)" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 064756499 . This is a "D-U-N-S #" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 705193 . This is a "SWAM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 712R4 . This is a "CAGE CODE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1699011312 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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