Healthcare Provider Details

I. General information

NPI: 1891188991
Provider Name (Legal Business Name): TIDEWATER DERMATOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2015
Last Update Date: 08/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 FRANKLIN AVE SUITE 107
BERLIN MD
21811-1215
US

IV. Provider business mailing address

314 FRANKLIN AVE SUITE 107
BERLIN MD
21811-1215
US

V. Phone/Fax

Practice location:
  • Phone: 410-641-2222
  • Fax: 844-715-9464
Mailing address:
  • Phone: 410-641-2222
  • Fax: 844-715-9464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ANNE P SPILLANE
Title or Position: MANAGING PARTNER
Credential: M.D.
Phone: 410-641-2222