Provider Demographics
NPI:1790830826
Name:FAMILY PHYSICIANS OF TIDEWATER PLLC
Entity Type:Organization
Organization Name:FAMILY PHYSICIANS OF TIDEWATER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CLEMENT
Authorized Official - Middle Name:STOKES
Authorized Official - Last Name:KIRKLAND
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:757-889-6520
Mailing Address - Street 1:110 KINGSLEY LN
Mailing Address - Street 2:SUITE 202
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23505-4614
Mailing Address - Country:US
Mailing Address - Phone:757-889-6520
Mailing Address - Fax:757-489-4905
Practice Address - Street 1:110 KINGSLEY LN
Practice Address - Street 2:SUITE 202
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-4614
Practice Address - Country:US
Practice Address - Phone:757-889-6520
Practice Address - Fax:757-489-4905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty