Healthcare Provider Details

I. General information

NPI: 1730214248
Provider Name (Legal Business Name): TIDEWATER FAMILY MEDICAL CARE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 07/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 INNOVATION DR STE 103
CHESAPEAKE VA
23320-3847
US

IV. Provider business mailing address

516 INNOVATION DR STE. 103
CHESAPEAKE VA
23320-3847
US

V. Phone/Fax

Practice location:
  • Phone: 757-495-0606
  • Fax:
Mailing address:
  • Phone: 757-495-0606
  • Fax: 757-495-0952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0102037087
License Number StateVA

VIII. Authorized Official

Name: DR. FRANK JOSEPH PICCIONI
Title or Position: PRESIDENT
Credential: D.O.
Phone: 757-495-0606