Healthcare Provider Details

I. General information

NPI: 1770519381
Provider Name (Legal Business Name): TIDEWATER SURGICAL SPECIALISTS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3205 CHURCHLAND BLVD
CHESAPEAKE VA
23321-5262
US

IV. Provider business mailing address

3205 CHURCHLAND BLVD
CHESAPEAKE VA
23321-5262
US

V. Phone/Fax

Practice location:
  • Phone: 757-483-3030
  • Fax: 757-484-7239
Mailing address:
  • Phone: 757-483-3030
  • Fax: 757-484-7239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: RAY T. RAMIREZ
Title or Position: CEO
Credential: M.D.
Phone: 757-483-3030