1104923895 NPI number — TIDEWATER MEDICAL SUPPLY, INC

Table of content: (NPI 1104923895)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104923895 NPI number — TIDEWATER MEDICAL SUPPLY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIDEWATER MEDICAL SUPPLY, 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:
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:
1104923895
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/11/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
525 BYRON ST
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
CHESAPEAKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23320-7967
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-548-9999
Provider Business Mailing Address Fax Number:
757-549-7752

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
525 BYRON ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
CHESAPEAKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23320-7967
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-548-9999
Provider Business Practice Location Address Fax Number:
757-549-7752
Provider Enumeration Date:
09/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIES
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
ANTHONY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
757-548-9999

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X , with the licence number:  0206009115 , 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)

  • Identifier: 1258980001 . This is a "MEDICARE PARTICIPATING PROVIDER ID # 1258980001 STATE VA PTAN #" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 009117920 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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