Provider Demographics
NPI:1073626396
Name:TIDEWATER DIAGNOSTIC IMAGING LTD
Entity Type:Organization
Organization Name:TIDEWATER DIAGNOSTIC IMAGING LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAVI
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAMAIENGAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-984-7911
Mailing Address - Street 1:PO BOX 844723
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-4723
Mailing Address - Country:US
Mailing Address - Phone:866-759-4524
Mailing Address - Fax:757-512-5025
Practice Address - Street 1:3000 COLISEUM DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-5963
Practice Address - Country:US
Practice Address - Phone:757-736-1621
Practice Address - Fax:757-512-5025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2021-08-18
Deactivation Date:2019-01-08
Deactivation Code:
Reactivation Date:2019-01-11
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA265930OtherANTHEM
VAC01646Medicare ID - Type Unspecified
VA265930OtherANTHEM