Provider Demographics
NPI:1770510695
Name:TIDEWATER INTERNAL MEDICINE, LLC
Entity Type:Organization
Organization Name:TIDEWATER INTERNAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:KINNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-571-6868
Mailing Address - Street 1:2097 HENRY TECKLENBURG DR
Mailing Address - Street 2:SUITE 220
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-5740
Mailing Address - Country:US
Mailing Address - Phone:843-571-6868
Mailing Address - Fax:843-571-6198
Practice Address - Street 1:2097 HENRY TECKLENBURG DR
Practice Address - Street 2:SUITE 220
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5740
Practice Address - Country:US
Practice Address - Phone:843-571-6868
Practice Address - Fax:843-571-6198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-27
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19466261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7832Medicare ID - Type Unspecified