1396869517 NPI number — TIDEWATER GASTROENTEROLOGY, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396869517 NPI number — TIDEWATER GASTROENTEROLOGY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIDEWATER GASTROENTEROLOGY, PLLC
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:
Provider Other Organization Name Type Code:
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:
1396869517
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
661 INDEPENDENCE PKWY STE 120
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHESAPEAKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23320-5164
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-547-0798
Provider Business Mailing Address Fax Number:
757-547-0145

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1101 FIRST COLONIAL RD
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
VIRGINIA BEACH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23454-2409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-481-4817
Provider Business Practice Location Address Fax Number:
757-963-5585
Provider Enumeration Date:
03/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DUNCAN
Authorized Official First Name:
MICHELE
Authorized Official Middle Name:
YVONNE
Authorized Official Title or Position:
OPERATIONS MANAGER
Authorized Official Telephone Number:
757-842-6001

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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