Healthcare Provider Details

I. General information

NPI: 1528007010
Provider Name (Legal Business Name): TIDEWATER INTEGRATED MEDICAL SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 03/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VIRGINIA BEACH GENERAL HOSPITAL 1060 FIRST COLONIAL RD
VIRGINIA BEACH VA
23450
US

IV. Provider business mailing address

PO BOX 2546
VIRGINIA BEACH VA
23450-2546
US

V. Phone/Fax

Practice location:
  • Phone: 757-340-3489
  • Fax: 757-340-4278
Mailing address:
  • Phone: 757-340-3489
  • Fax: 757-340-4278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. EDWARD THOMAS
Title or Position: DOCTOR
Credential: MD
Phone: 757-340-3489