Provider Demographics
NPI:1013008861
Name:OPHTHALMIC CONSULTANTS OF TIDEWATER PC
Entity Type:Organization
Organization Name:OPHTHALMIC CONSULTANTS OF TIDEWATER PC
Other - Org Name:MID ATLANTIC EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WALLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-547-9830
Mailing Address - Street 1:109 WIMBLEDON SQ
Mailing Address - Street 2:SUITE E
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-4945
Mailing Address - Country:US
Mailing Address - Phone:757-547-9830
Mailing Address - Fax:757-548-0721
Practice Address - Street 1:109 WIMBLEDON SQ
Practice Address - Street 2:SUITE E
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4945
Practice Address - Country:US
Practice Address - Phone:757-547-9830
Practice Address - Fax:757-548-0721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC04070Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBERS