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General NPI Number Information
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NPI Number | 1417992686
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Entity Type | Organization
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Legal Business Name | TIDEWATER HEART SPECIALISTS, INC.
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Dates
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Enumeration Date | 06/19/2006
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 2112 HARTFORD RD STE B
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City | HAMPTON
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State | VA
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Zip | 23666-6601
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Country | US
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Telephone | 757-827-7754
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Fax |
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Provider Business Mailing Address
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Address Line | 2112 HARTFORD RD STE B
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City | HAMPTON
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State | VA
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Zip | 23666-6601
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MARK W CLARK
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Credential | M.D.
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Telephone | 757-827-7754
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State | VA
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