1053558981 NPI number — TIDEWATER MEDICAL CARE PC

Table of content: (NPI 1053558981)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053558981 NPI number — TIDEWATER MEDICAL CARE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIDEWATER MEDICAL CARE PC
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 CARE PC
Provider Other Organization Name Type Code:
3
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:
1053558981
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/03/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4608 THOROUGHGOOD DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIRGINIA BEACH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23455
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-965-9465
Provider Business Mailing Address Fax Number:
757-965-9491

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4608 THOROUGHGOOD DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VIRGINIA BEACH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-965-9465
Provider Business Practice Location Address Fax Number:
757-965-9491
Provider Enumeration Date:
01/14/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MONTEJO
Authorized Official First Name:
MIGDONIA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
757-965-9465

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  0101058505 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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