Healthcare Provider Details

I. General information

NPI: 1396869517
Provider Name (Legal Business Name): TIDEWATER GASTROENTEROLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 03/27/2023
Certification Date: 03/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 FIRST COLONIAL RD SUITE 300
VIRGINIA BEACH VA
23454-2409
US

IV. Provider business mailing address

661 INDEPENDENCE PKWY STE 120
CHESAPEAKE VA
23320-5164
US

V. Phone/Fax

Practice location:
  • Phone: 757-481-4817
  • Fax: 757-963-5585
Mailing address:
  • Phone: 757-547-0798
  • Fax: 757-547-0145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MICHELE YVONNE DUNCAN
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 757-842-6001