1124060314 NPI number — CLINICAL ASSOCIATES OF TIDEWATER, P.C.

Table of content: (NPI 1124060314)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124060314 NPI number — CLINICAL ASSOCIATES OF TIDEWATER, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLINICAL ASSOCIATES OF TIDEWATER, P.C.
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:
1124060314
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6320 N CENTER DR
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
NORFOLK
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23502-4009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-456-0505
Provider Business Mailing Address Fax Number:
757-456-0817

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6320 N CENTER DR
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:
23502-4009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-456-0505
Provider Business Practice Location Address Fax Number:
757-456-0817
Provider Enumeration Date:
06/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
REID
Authorized Official First Name:
REBECCA
Authorized Official Middle Name:
DEAN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
757-456-0505

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 8917124 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6717951 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7704241 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7730667 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 216460 . This is a "MARK YARHOUSE-ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 72705 . This is a "NANCY PASCHALL-ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 7702451 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7761775 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 322713 . This is a "FRANK AIELLO,MD - ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 72702 . This is a "REBECCA REID - ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 93140 . This is a "CAROLYN JOHNSON-ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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