Healthcare Provider Details

I. General information

NPI: 1699011312
Provider Name (Legal Business Name): TIDEWATER MEDICAL TRANSPORT, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2012
Last Update Date: 06/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2503 WOODROW ST STE 8
PORTSMOUTH VA
23707-2124
US

IV. Provider business mailing address

2503 WOODROW ST SUITE 8
PORTSMOUTH VA
23707-2124
US

V. Phone/Fax

Practice location:
  • Phone: 757-399-0999
  • Fax: 757-399-1999
Mailing address:
  • Phone: 757-399-0999
  • Fax: 757-399-1999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code341600000X
TaxonomyAmbulance
License Number0786425-9
License Number StateVA

VIII. Authorized Official

Name: MRS. BARBARA DAWN SMITH
Title or Position: PRESIDENT-OWNER
Credential:
Phone: 757-399-0999