Provider Demographics
NPI:1891188991
Name:TIDEWATER DERMATOLOGY, LLC
Entity Type:Organization
Organization Name:TIDEWATER DERMATOLOGY, LLC
Other - Org Name:TIDEWATER DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:P
Authorized Official - Last Name:SPILLANE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-641-2222
Mailing Address - Street 1:314 FRANKLIN AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-1215
Mailing Address - Country:US
Mailing Address - Phone:410-641-2222
Mailing Address - Fax:844-715-9464
Practice Address - Street 1:314 FRANKLIN AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-1215
Practice Address - Country:US
Practice Address - Phone:410-641-2222
Practice Address - Fax:844-715-9464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-13
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty