Healthcare Provider Details

I. General information

NPI: 1942300298
Provider Name (Legal Business Name): TIDEWATER GASTROENTEROLOGY,PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

661 INDEPENDENCE PKWY STE 120
CHESAPEAKE VA
23320-5164
US

IV. Provider business mailing address

PO BOX 381468
GERMANTOWN TN
38183-1468
US

V. Phone/Fax

Practice location:
  • Phone: 757-547-0798
  • Fax: 757-547-0145
Mailing address:
  • Phone: 901-737-4665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number0101023966
License Number StateVA

VIII. Authorized Official

Name: MRS. AIMEE CATHLEEN JUDY
Title or Position: DIRECTOR, CREDENTIALING
Credential:
Phone: 901-737-4665