Healthcare Provider Details

I. General information

NPI: 1467461822
Provider Name (Legal Business Name): TIDEWATER NEPHROLOGY LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 03/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 CAMELOT DR SUITE 401
VIRGINIA BEACH VA
23454-2440
US

IV. Provider business mailing address

1800 CAMELOT DR SUITE 401
VIRGINIA BEACH VA
23454-2440
US

V. Phone/Fax

Practice location:
  • Phone: 757-496-3706
  • Fax: 757-496-3715
Mailing address:
  • Phone: 757-496-3706
  • Fax: 757-496-3715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101027286
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number0101027286
License Number StateVA

VIII. Authorized Official

Name: DAVID WALKER BEST
Title or Position: CEO/PRESIDENT.
Credential: MD
Phone: 757-496-3706