Provider Demographics
NPI:1841298759
Name:TIDEWATER PED. CONSULTANTS, PC
Entity type:Organization
Organization Name:TIDEWATER PED. CONSULTANTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSETTA
Authorized Official - Middle Name:S
Authorized Official - Last Name:CHERRY
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:757-420-0487
Mailing Address - Street 1:6477 COLLEGE PARK SQ
Mailing Address - Street 2:STE 118
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-3611
Mailing Address - Country:US
Mailing Address - Phone:757-420-6218
Mailing Address - Fax:757-420-0487
Practice Address - Street 1:6477 COLLEGE PARK SQ
Practice Address - Street 2:STE 118
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-3611
Practice Address - Country:US
Practice Address - Phone:757-420-6218
Practice Address - Fax:757-420-0487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA002500-8011208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty