Provider Demographics
NPI:1164613543
Name:TIDEWATER HEART LABORATORIES
Entity Type:Organization
Organization Name:TIDEWATER HEART LABORATORIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HERRING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-825-4260
Mailing Address - Street 1:2115 EXECUTIVE DR
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666
Mailing Address - Country:US
Mailing Address - Phone:757-825-4260
Mailing Address - Fax:757-825-4265
Practice Address - Street 1:2116 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2402
Practice Address - Country:US
Practice Address - Phone:757-224-4233
Practice Address - Fax:757-224-4955
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TIDEWATER HEART INSTITUTE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-09
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAB05848Medicare UPIN