MEDICARE: TIDEWATER PED. CONSULTANTS, PC

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	208000000X	Pediatrics Physician	002500-8011	VA

General Provider Information

NPI Number	:	1841298759
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIDEWATER PED. CONSULTANTS, PC

Provider Business Mailing Address
First Line	:	6477 COLLEGE PARK SQ
Second Line	:	STE 118
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-3611
Country	:	US
Telephone Number	:	757-420-6218
Fax Number	:	757-420-0487

Provider Business Practice Location Address
First Line	:	6477 COLLEGE PARK SQ
Second Line	:	STE 118
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-3611
Country	:	US
Telephone Number	:	757-420-6218
Fax Number	:	757-420-0487

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	MRS. ROSETTA S CHERRY
Credential	:	LPN
Telephone Number	:	757-420-0487

Provider Enumeration Date	:	07/13/2005
Last Update Date	:	08/22/2020

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