MEDICARE: TIDEWATER KIDNEY SPECIALISTS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	2085R0204X	Vascular & Interventional Radiology Physician
2	2086S0129X	Vascular Surgery Physician
3	207RN0300X	Nephrology Physician

General Provider Information

NPI Number	:	1053678839
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIDEWATER KIDNEY SPECIALISTS, INC.

Provider Business Mailing Address
First Line	:	4445 CORPORATION LN STE 100
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-3666
Country	:	US
Telephone Number	:	757-623-0005
Fax Number	:	757-548-1129

Provider Business Practice Location Address
First Line	:	814 KEMPSVILLE RD
Second Line	:	SUITE 101
City	:	NORFOLK
State	:	VA
Zip	:	23502-4001
Country	:	US
Telephone Number	:	757-623-0005
Fax Number	:	757-548-1129

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	MRS. ELIZABETH F SKIDMORE
Credential	:
Telephone Number	:	757-623-0005

Provider Enumeration Date	:	04/18/2012
Last Update Date	:	01/20/2022

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