Provider Demographics
NPI:1073521548
Name:CANCER SPECIALISTS OF TIDEWATER, LTD.
Entity Type:Organization
Organization Name:CANCER SPECIALISTS OF TIDEWATER, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:PERNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-436-1492
Mailing Address - Street 1:110 WIMBLEDON SQ
Mailing Address - Street 2:SUITE E
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-4946
Mailing Address - Country:US
Mailing Address - Phone:757-436-1492
Mailing Address - Fax:757-436-2912
Practice Address - Street 1:110 WIMBLEDON SQ
Practice Address - Street 2:SUITE E
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4946
Practice Address - Country:US
Practice Address - Phone:757-436-1492
Practice Address - Fax:757-436-2912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA033518OtherANTHEM
890511HOtherNORTH CAROLINA MEDICAID
VA35037OtherOPTIMA/SENTARA
890584TOtherNORTH CAROLINA MEDICAID
VA093213OtherANTHEM
VA52831OtherOPTIMA/SENTARA
VA60-48030Medicaid
830007176OtherRAILROAD MEDICARE
890500WOtherNORTH CAROLINA MEDICAID
830003514OtherRAILROAD MEDICARE
VA265950OtherANTHEM
900001703OtherRAILROAD MEDICARE
VA58-45521Medicaid
VA110004487Medicare ID - Type Unspecified
VA830000147Medicare ID - Type Unspecified
VA093213OtherANTHEM
890584TOtherNORTH CAROLINA MEDICAID
890511HOtherNORTH CAROLINA MEDICAID
830007176OtherRAILROAD MEDICARE
VA58-45521Medicaid