Provider Demographics
NPI:1699011312
Name:TIDEWATER MEDICAL TRANSPORT, INC
Entity Type:Organization
Organization Name:TIDEWATER MEDICAL TRANSPORT, INC
Other - Org Name:TIDEWATER MEDICAL TRANSPORT LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT-OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-399-0999
Mailing Address - Street 1:2503 WOODROW ST
Mailing Address - Street 2:SUITE 8
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-2124
Mailing Address - Country:US
Mailing Address - Phone:757-399-0999
Mailing Address - Fax:757-399-1999
Practice Address - Street 1:2503 WOODROW ST STE 8
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-2124
Practice Address - Country:US
Practice Address - Phone:757-399-0999
Practice Address - Fax:757-399-1999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-27
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0786425-9341600000X
3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
No3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0786425-9OtherSTATE CORPORATION COMMISSION
VA01333OtherVIRGINIA OFFICE OF EMERGENCY MEDICAL SERVICES (VAOEMS)
VA064756499OtherD-U-N-S #
VA705193OtherSWAM
712R4OtherCAGE CODE
VA1699011312Medicaid