Healthcare Provider Details

I. General information

NPI: 1235417833
Provider Name (Legal Business Name): TIDEWATER PATHOLOGY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2011
Last Update Date: 08/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

924 EASTERN SHORE RD
VIRGINIA BEACH VA
23454-3504
US

IV. Provider business mailing address

PO BOX 640
BELLEVILLE NJ
07109-0640
US

V. Phone/Fax

Practice location:
  • Phone: 757-362-4051
  • Fax: 757-425-1834
Mailing address:
  • Phone: 973-751-7515
  • Fax: 973-751-1394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: SAVVAS E MENDRINOS
Title or Position: OWNER
Credential: MD
Phone: 757-362-4051