Provider Demographics
NPI:1245336510
Name:PULMONARY PHYSICIANS OF TIDEWATER PC
Entity type:Organization
Organization Name:PULMONARY PHYSICIANS OF TIDEWATER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:IRA
Authorized Official - Last Name:GRAYSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-460-9200
Mailing Address - Street 1:PO BOX 68067
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23471-8067
Mailing Address - Country:US
Mailing Address - Phone:757-460-9200
Mailing Address - Fax:757-460-6553
Practice Address - Street 1:816 INDEPENDENCE BOULEVARD
Practice Address - Street 2:SUITE 2-B
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-6010
Practice Address - Country:US
Practice Address - Phone:757-460-9200
Practice Address - Fax:757-460-6553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C02126Medicare UPIN