Provider Demographics
NPI:1154550879
Name:TIDEWATER EYE CENTERS
Entity type:Organization
Organization Name:TIDEWATER EYE CENTERS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:QUATTLEBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-397-7858
Mailing Address - Street 1:3235 ACADEMY AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-3200
Mailing Address - Country:US
Mailing Address - Phone:757-397-4666
Mailing Address - Fax:757-673-6832
Practice Address - Street 1:3235 ACADEMY AVE STE 200
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703
Practice Address - Country:US
Practice Address - Phone:757-397-2020
Practice Address - Fax:757-397-8766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-02
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1276560003Medicare NSC