Provider Demographics
NPI:1053678839
Name:TIDEWATER KIDNEY SPECIALISTS, INC.
Entity Type:Organization
Organization Name:TIDEWATER KIDNEY SPECIALISTS, INC.
Other - Org Name:TIDEWATER VASCULAR ACCESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:F
Authorized Official - Last Name:SKIDMORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-623-0005
Mailing Address - Street 1:4445 CORPORATION LN STE 100
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-3666
Mailing Address - Country:US
Mailing Address - Phone:757-623-0005
Mailing Address - Fax:757-548-1129
Practice Address - Street 1:814 KEMPSVILLE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-4001
Practice Address - Country:US
Practice Address - Phone:757-623-0005
Practice Address - Fax:757-548-1129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-18
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty