Healthcare Provider Details

I. General information

NPI: 1689623258
Provider Name (Legal Business Name): TIDEWATER NEUROLOGISTS INC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3235 ACADEMY AVE SUITE 305
PORTSMOUTH VA
23703-3200
US

IV. Provider business mailing address

3235 ACADEMY AVE STE 305
PORTSMOUTH VA
23703-3200
US

V. Phone/Fax

Practice location:
  • Phone: 757-686-9300
  • Fax: 757-686-1514
Mailing address:
  • Phone: 757-463-5240
  • Fax: 757-463-6572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. HEMANG H SHAH
Title or Position: OWNER
Credential: MD
Phone: 757-686-9300