Provider Demographics
NPI:1154496776
Name:NEUROLOGY CONSULANTS OF TIDEWATER PLLC
Entity Type:Organization
Organization Name:NEUROLOGY CONSULANTS OF TIDEWATER PLLC
Other - Org Name:VIRGINIA BEACH NEUROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:J
Authorized Official - Last Name:GLOVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-481-3808
Mailing Address - Street 1:968 FIRST COLONIAL RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-3171
Mailing Address - Country:US
Mailing Address - Phone:757-481-3808
Mailing Address - Fax:
Practice Address - Street 1:968 FIRST COLONIAL RD
Practice Address - Street 2:SUITE 103
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-3171
Practice Address - Country:US
Practice Address - Phone:757-481-3808
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101052447174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05871Medicare PIN