Healthcare Provider Details

I. General information

NPI: 1104923895
Provider Name (Legal Business Name): TIDEWATER MEDICAL SUPPLY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2006
Last Update Date: 03/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 BYRON ST SUITE A
CHESAPEAKE VA
23320-7967
US

IV. Provider business mailing address

525 BYRON ST SUITE A
CHESAPEAKE VA
23320-7967
US

V. Phone/Fax

Practice location:
  • Phone: 757-548-9999
  • Fax: 757-549-7752
Mailing address:
  • Phone: 757-548-9999
  • Fax: 757-549-7752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number0206009115
License Number StateVA

VIII. Authorized Official

Name: MR. KEITH ANTHONY DAVIES
Title or Position: PRESIDENT
Credential:
Phone: 757-548-9999