Provider Demographics
NPI:1922339076
Name:TIDEWATER BARIATRICS
Entity Type:Organization
Organization Name:TIDEWATER BARIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:MACKRELL
Authorized Official - Last Name:GAGLIONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-644-6819
Mailing Address - Street 1:1413 KEMPSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-8134
Mailing Address - Country:US
Mailing Address - Phone:757-644-6819
Mailing Address - Fax:757-644-6816
Practice Address - Street 1:1413 KEMPSVILLE RD
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-8134
Practice Address - Country:US
Practice Address - Phone:757-644-6819
Practice Address - Fax:757-644-6816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-28
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101050879261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty