Provider Demographics
NPI:1528007010
Name:TIDEWATER INTEGRATED MEDICAL SERVICES, PLLC
Entity Type:Organization
Organization Name:TIDEWATER INTEGRATED MEDICAL SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-340-3489
Mailing Address - Street 1:PO BOX 2546
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23450-2546
Mailing Address - Country:US
Mailing Address - Phone:757-340-3489
Mailing Address - Fax:757-340-4278
Practice Address - Street 1:VIRGINIA BEACH GENERAL HOSPITAL
Practice Address - Street 2:1060 FIRST COLONIAL RD
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23450
Practice Address - Country:US
Practice Address - Phone:757-340-3489
Practice Address - Fax:757-340-4278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1528007010Medicaid
VAC06289Medicare PIN