Provider Demographics
NPI:1891113155
Name:TIDEWATER REHABILITATION MEDICINE
Entity Type:Organization
Organization Name:TIDEWATER REHABILITATION MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER/AUTHORIZE OFFICIAL
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:KAYOTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-496-2325
Mailing Address - Street 1:1120 FIRST COLONIAL RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-2418
Mailing Address - Country:US
Mailing Address - Phone:757-496-2325
Mailing Address - Fax:757-496-1942
Practice Address - Street 1:1120 FIRST COLONIAL RD
Practice Address - Street 2:SUITE 206
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2418
Practice Address - Country:US
Practice Address - Phone:757-496-2325
Practice Address - Fax:757-496-1942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-03
Last Update Date:2015-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101053621208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1891113155OtherAETNA
VA1891113155OtherANTHEM BCBS VA
VA1891113155Medicaid
VA1891113155OtherOPTIMA
VA1891113155OtherCOVENTRY
VA1891113155OtherHUMANA MEDICARE
VA1891113155OtherCIGNA
VA1891113155OtherVIRGINIA HEALTH NETWORK
VA1891113155OtherUNITED HEALTHCARE
VA618120600OtherDEPARTMENT OF LABOR
VA1891113155OtherTRICARE
VA1891113155OtherCOVENTRY