Provider Demographics
NPI:1427438373
Name:GASTROINTESTINAL AND LIVER SPECIALISTS OF TIDEWATER, PLLC
Entity type:Organization
Organization Name:GASTROINTESTINAL AND LIVER SPECIALISTS OF TIDEWATER, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:GLADYS
Authorized Official - Middle Name:ARLENE
Authorized Official - Last Name:DAVIES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-464-1644
Mailing Address - Street 1:1020 INDEPENDENCE BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-5500
Mailing Address - Country:US
Mailing Address - Phone:757-464-1644
Mailing Address - Fax:757-363-1071
Practice Address - Street 1:1020 INDEPENDENCE BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-5500
Practice Address - Country:US
Practice Address - Phone:757-464-1644
Practice Address - Fax:757-363-1071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-05
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty