1639138365 NPI number — TIDEWATER INTERNAL MEDICINE ASSOCIATES, P.C.

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 1639138365 NPI number — TIDEWATER INTERNAL MEDICINE ASSOCIATES, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIDEWATER INTERNAL MEDICINE ASSOCIATES, 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:
1639138365
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11768
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23230-0168
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-353-4000
Provider Business Mailing Address Fax Number:
804-213-9783

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2115 EXECUTIVE DR
Provider Second Line Business Practice Location Address:
SUITE 4-B
Provider Business Practice Location Address City Name:
HAMPTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23666-2499
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-838-2891
Provider Business Practice Location Address Fax Number:
757-838-6108
Provider Enumeration Date:
03/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CHINNERY
Authorized Official First Name:
LIND
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
757-838-2891

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: C05867 . This is a "MEDICARE GROUP NUMBER" identifier . This identifiers is of the category "OTHER".




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