1053678839 NPI number — TIDEWATER KIDNEY SPECIALISTS, INC.

Table of content: (NPI 1053678839)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053678839 NPI number — TIDEWATER KIDNEY SPECIALISTS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIDEWATER KIDNEY SPECIALISTS, 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:
Provider Other Organization Name Type Code:
6
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:
1053678839
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4445 CORPORATION LN STE 100
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:
23462-3666
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-623-0005
Provider Business Mailing Address Fax Number:
757-548-1129

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
814 KEMPSVILLE RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
NORFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23502-4001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-623-0005
Provider Business Practice Location Address Fax Number:
757-548-1129
Provider Enumeration Date:
04/18/2012

Additional Information

Authorized Official

Authorized Official Last Name:
SKIDMORE
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
F
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
757-623-0005

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0204X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0129X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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