Provider Demographics
NPI:1053447839
Name:TIDEWATER EAR, NOSE, & THROAT, INC.
Entity Type:Organization
Organization Name:TIDEWATER EAR, NOSE, & THROAT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:WRENN
Authorized Official - Last Name:MURDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-488-2080
Mailing Address - Street 1:4020 RAINTREE RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-3749
Mailing Address - Country:US
Mailing Address - Phone:757-488-2080
Mailing Address - Fax:757-405-3025
Practice Address - Street 1:4020 RAINTREE RD
Practice Address - Street 2:SUITE C
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-3749
Practice Address - Country:US
Practice Address - Phone:757-488-2080
Practice Address - Fax:757-405-3025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101016485174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006501320Medicaid
VAB05116Medicare UPIN