Provider Demographics
NPI:1689623258
Name:TIDEWATER NEUROLOGISTS INC, PC
Entity Type:Organization
Organization Name:TIDEWATER NEUROLOGISTS INC, PC
Other - Org Name:TIDEWATER NEUROLOGISTS AND SLEEP DISORDER SPECIALIST, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HEMANG
Authorized Official - Middle Name:H
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-686-9300
Mailing Address - Street 1:3235 ACADEMY AVE STE 305
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-3200
Mailing Address - Country:US
Mailing Address - Phone:757-463-5240
Mailing Address - Fax:757-463-6572
Practice Address - Street 1:3235 ACADEMY AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703-3200
Practice Address - Country:US
Practice Address - Phone:757-686-9300
Practice Address - Fax:757-686-1514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical NeurophysiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA200250OtherSENTARA
VA=========OtherWPS TRICARE FOR LIFE
VA=========OtherHEALTHNET TRICARE CHAMPUS
VAC05873Medicare PIN
VA=========OtherHEALTHNET TRICARE CHAMPUS