Provider Demographics
NPI:1396869517
Name:TIDEWATER GASTROENTEROLOGY, PLLC
Entity type:Organization
Organization Name:TIDEWATER GASTROENTEROLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:YVONNE
Authorized Official - Last Name:DUNCAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-842-6001
Mailing Address - Street 1:661 INDEPENDENCE PKWY STE 120
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-5164
Mailing Address - Country:US
Mailing Address - Phone:757-547-0798
Mailing Address - Fax:757-547-0145
Practice Address - Street 1:1101 FIRST COLONIAL RD
Practice Address - Street 2:SUITE 300
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2409
Practice Address - Country:US
Practice Address - Phone:757-481-4817
Practice Address - Fax:757-963-5585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty