Basic Information
| Provider Information | |||||||||
| NPI: | 1528007010 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TIDEWATER INTEGRATED MEDICAL SERVICES, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2546 | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234502546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573403489 | ||||||||
| FaxNumber: | 7573404278 | ||||||||
| Practice Location | |||||||||
| Address1: | VIRGINIA BEACH GENERAL HOSPITAL | ||||||||
| Address2: | 1060 FIRST COLONIAL RD | ||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573403489 | ||||||||
| FaxNumber: | 7573404278 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 03/09/2015 | ||||||||
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| AuthorizedOfficialLastName: | THOMAS | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 7573403489 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 207RC0200X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RG0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1528007010 | 05 | VA | MEDICAID |