Healthcare Provider Details

I. General information

NPI: 1053678839
Provider Name (Legal Business Name): TIDEWATER KIDNEY SPECIALISTS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2012
Last Update Date: 01/20/2022
Certification Date: 01/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

814 KEMPSVILLE RD SUITE 101
NORFOLK VA
23502-4001
US

IV. Provider business mailing address

4445 CORPORATION LN STE 100
VIRGINIA BEACH VA
23462-3666
US

V. Phone/Fax

Practice location:
  • Phone: 757-623-0005
  • Fax: 757-548-1129
Mailing address:
  • Phone: 757-623-0005
  • Fax: 757-548-1129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. ELIZABETH F SKIDMORE
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 757-623-0005