Provider Demographics
NPI:1477680858
Name:TIDEWATER FAMILY MEDICINE, P C
Entity Type:Organization
Organization Name:TIDEWATER FAMILY MEDICINE, P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:C
Authorized Official - Last Name:HYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-826-3460
Mailing Address - Street 1:2114A HARTFORD RD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-2409
Mailing Address - Country:US
Mailing Address - Phone:757-826-3460
Mailing Address - Fax:757-826-5123
Practice Address - Street 1:2114A HARTFORD RD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2409
Practice Address - Country:US
Practice Address - Phone:757-826-3460
Practice Address - Fax:757-826-5123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5696615Medicaid
B59571Medicare UPIN
VA5696615Medicaid