Basic Information
| Provider Information | |||||||||
| NPI: | 1932870318 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TIDEWATER DOCTORS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2834 AQUADUCT ST | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294147410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432007721 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2270 ASHLEY CROSSING DR STE 150 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294145702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437661936 | ||||||||
| FaxNumber: | 8437661206 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2021 | ||||||||
| LastUpdateDate: | 09/24/2021 | ||||||||
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| AuthorizedOfficialLastName: | HURLEY | ||||||||
| AuthorizedOfficialFirstName: | ANDREA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8432007721 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.