MEDICARE: TIDEWATER HEART SPECIALISTS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist		VA

General Provider Information

NPI Number	:	1417992686
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIDEWATER HEART SPECIALISTS, INC.

Provider Business Mailing Address
First Line	:	2112 HARTFORD RD STE B
Second Line	:
City	:	HAMPTON
State	:	VA
Zip	:	23666-6601
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2112 HARTFORD RD STE B
Second Line	:
City	:	HAMPTON
State	:	VA
Zip	:	23666-6601
Country	:	US
Telephone Number	:	757-827-7754
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MARK W CLARK
Credential	:	M.D.
Telephone Number	:	757-827-7754

Provider Enumeration Date	:	06/19/2006
Last Update Date	:	07/21/2022

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