Provider Demographics
NPI:1710293212
Name:TIDEWATER INTEGRATIVE HEALTH PC
Entity Type:Organization
Organization Name:TIDEWATER INTEGRATIVE HEALTH PC
Other - Org Name:SB HUDSON MD PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:HUNT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-497-0606
Mailing Address - Street 1:802 NORTH NEWTOWN RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-1116
Mailing Address - Country:US
Mailing Address - Phone:757-497-0606
Mailing Address - Fax:757-497-0411
Practice Address - Street 1:802 NORTH NEWTOWN RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-1116
Practice Address - Country:US
Practice Address - Phone:757-497-0606
Practice Address - Fax:757-497-0411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-23
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101035294207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAB03962Medicare UPIN