=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841298759
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TIDEWATER PED. CONSULTANTS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6477 COLLEGE PARK SQ STE 118
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23464-3611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-420-6218
-----------------------------------------------------
Fax | 757-420-0487
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6477 COLLEGE PARK SQ STE 118
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23464-3611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-420-6218
-----------------------------------------------------
Fax | 757-420-0487
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | MRS. ROSETTA S CHERRY
-----------------------------------------------------
Credential | LPN
-----------------------------------------------------
Telephone | 757-420-0487
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 002500-8011
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------