=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922339076
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TIDEWATER BARIATRICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2010
-----------------------------------------------------
Last Update Date | 01/28/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1413 KEMPSVILLE RD
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23320-8134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-644-6819
-----------------------------------------------------
Fax | 757-644-6816
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1413 KEMPSVILLE RD
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23320-8134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-644-6819
-----------------------------------------------------
Fax | 757-644-6816
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | MRS. MARGARET MACKRELL GAGLIONE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 757-644-6819
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 0101050879
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------