Provider Demographics
NPI:1639138365
Name:TIDEWATER INTERNAL MEDICINE ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:TIDEWATER INTERNAL MEDICINE ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LIND
Authorized Official - Middle Name:W
Authorized Official - Last Name:CHINNERY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-838-2891
Mailing Address - Street 1:PO BOX 11768
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-0168
Mailing Address - Country:US
Mailing Address - Phone:804-353-4000
Mailing Address - Fax:804-213-9783
Practice Address - Street 1:2115 EXECUTIVE DR
Practice Address - Street 2:SUITE 4-B
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2499
Practice Address - Country:US
Practice Address - Phone:757-838-2891
Practice Address - Fax:757-838-6108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C05867OtherMEDICARE GROUP NUMBER