=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801289392
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TIDEWATER RADIATION SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2015
-----------------------------------------------------
Last Update Date | 03/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1144 N ROAD ST
-----------------------------------------------------
City | ELIZABETH CITY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27909-3473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-384-4122
-----------------------------------------------------
Fax | 252-384-4220
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 31476
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23294-1476
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-266-8717
-----------------------------------------------------
Fax | 804-266-5677
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JANETE M MILLS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 252-384-4122
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0001X
-----------------------------------------------------
Taxonomy Name | Radiation Oncology Physician
-----------------------------------------------------
License Number | 2013-00861
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------