Provider Demographics
NPI:1386632495
Name:TIDEWATER TLC FAMILY CARE PLLC
Entity Type:Organization
Organization Name:TIDEWATER TLC FAMILY CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLOWE
Authorized Official - Suffix:
Authorized Official - Credentials:MD FAAFP
Authorized Official - Phone:757-436-6959
Mailing Address - Street 1:745 BATTLEFIELD BLVD N
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-0305
Mailing Address - Country:US
Mailing Address - Phone:757-436-6959
Mailing Address - Fax:757-549-1933
Practice Address - Street 1:745 BATTLEFIELD BLVD N
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-0305
Practice Address - Country:US
Practice Address - Phone:757-436-6959
Practice Address - Fax:757-549-1933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
54190784OtherTRICARE
57786OtherOPTIMAHEALTH PPO AND HMO
393970OtherANTHEM BCBS PPO
=========OtherHEALTHNET
=========OtherVIRGINIA HEALTH NETWORK
=========OtherCIGNA PPO
=========OtherUNITED HEALTHCARE (UHC)
54190784OtherTRICARE
=========OtherPHCS
F52972Medicare UPIN