Provider Demographics
NPI:1013088186
Name:CONVENIENT CARE OF TIDEWATER
Entity Type:Organization
Organization Name:CONVENIENT CARE OF TIDEWATER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-549-0222
Mailing Address - Street 1:PO BOX 2518
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23327-2518
Mailing Address - Country:US
Mailing Address - Phone:757-549-0222
Mailing Address - Fax:
Practice Address - Street 1:113 GAINSBOROUGH SQ
Practice Address - Street 2:SUITE 103
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-1713
Practice Address - Country:US
Practice Address - Phone:757-549-0222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-12
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101050282207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA72637OtherOPTIMA
VA104078OtherANTHEM
VA0004520572OtherAETNA
VA010041741Medicaid
VAMEDCOOther75063
VA010041741Medicaid
VAMEDCOOther75063
VA104078OtherANTHEM
VA72637OtherOPTIMA