Healthcare Provider Details

I. General information

NPI: 1053447839
Provider Name (Legal Business Name): TIDEWATER EAR, NOSE, & THROAT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 07/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4020 RAINTREE RD SUITE C
CHESAPEAKE VA
23321-3749
US

IV. Provider business mailing address

4020 RAINTREE RD SUITE C
CHESAPEAKE VA
23321-3749
US

V. Phone/Fax

Practice location:
  • Phone: 757-488-2080
  • Fax: 757-405-3025
Mailing address:
  • Phone: 757-488-2080
  • Fax: 757-405-3025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number0101016485
License Number StateVA

VIII. Authorized Official

Name: ANGELA WRENN MURDEN
Title or Position: INSURANCE COORDINATOR
Credential:
Phone: 757-488-2080