Provider Demographics
NPI:1497813158
Name:TIDEWATER FOOT & ANKLE CENTER, PC
Entity Type:Organization
Organization Name:TIDEWATER FOOT & ANKLE CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:P
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:757-497-7575
Mailing Address - Street 1:PO BOX 55350
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23471-9350
Mailing Address - Country:US
Mailing Address - Phone:757-497-7575
Mailing Address - Fax:
Practice Address - Street 1:760 INDEPENDENCE BLVD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-6206
Practice Address - Country:US
Practice Address - Phone:757-497-7575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA480000051OtherMEDICARE ID
VA9301658Medicaid
VA0574290001Medicare NSC
VA480000051OtherMEDICARE ID
VAT21968Medicare UPIN