Provider Demographics
NPI:1467461822
Name:TIDEWATER NEPHROLOGY LTD
Entity Type:Organization
Organization Name:TIDEWATER NEPHROLOGY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT.
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:WALKER
Authorized Official - Last Name:BEST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-496-3706
Mailing Address - Street 1:1800 CAMELOT DR
Mailing Address - Street 2:SUITE 401
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-2440
Mailing Address - Country:US
Mailing Address - Phone:757-496-3706
Mailing Address - Fax:757-496-3715
Practice Address - Street 1:1800 CAMELOT DR
Practice Address - Street 2:SUITE 401
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2440
Practice Address - Country:US
Practice Address - Phone:757-496-3706
Practice Address - Fax:757-496-3715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101027286207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006046983Medicaid
VABLUE CROSS BLUE SHIEOtherBCBS
B09078Medicare UPIN
110003709Medicare ID - Type Unspecified