Provider Demographics
NPI:1104923895
Name:TIDEWATER MEDICAL SUPPLY, INC
Entity type:Organization
Organization Name:TIDEWATER MEDICAL SUPPLY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:DAVIES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-548-9999
Mailing Address - Street 1:525 BYRON ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-7967
Mailing Address - Country:US
Mailing Address - Phone:757-548-9999
Mailing Address - Fax:757-549-7752
Practice Address - Street 1:525 BYRON ST
Practice Address - Street 2:SUITE A
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-7967
Practice Address - Country:US
Practice Address - Phone:757-548-9999
Practice Address - Fax:757-549-7752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-17
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0206009115332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1258980001OtherMEDICARE PARTICIPATING PROVIDER ID # 1258980001 STATE VA PTAN #
VA009117920Medicaid
1258980001Medicare ID - Type Unspecified