Provider Demographics
NPI:1225081201
Name:TIDEWATER HEART INSTITUTE INC
Entity Type:Organization
Organization Name:TIDEWATER HEART INSTITUTE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLERICAL
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-825-4260
Mailing Address - Street 1:2116 EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-2402
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:757-825-4260
Practice Address - Fax:757-825-4265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC01061Medicare UPIN