Provider Demographics
NPI:1942300298
Name:TIDEWATER GASTROENTEROLOGY,PLLC
Entity type:Organization
Organization Name:TIDEWATER GASTROENTEROLOGY,PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, CREDENTIALING
Authorized Official - Prefix:MRS
Authorized Official - First Name:AIMEE
Authorized Official - Middle Name:CATHLEEN
Authorized Official - Last Name:JUDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-737-4665
Mailing Address - Street 1:PO BOX 381468
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38183-1468
Mailing Address - Country:US
Mailing Address - Phone:901-737-4665
Mailing Address - Fax:
Practice Address - Street 1:661 INDEPENDENCE PKWY STE 120
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-5164
Practice Address - Country:US
Practice Address - Phone:757-547-0798
Practice Address - Fax:757-547-0145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101023966207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADC5759OtherRAILROAD MEDICARE GROUP #
VA159372OtherANTHEM GROUP #
VA131381OtherOPTIMA GROUP #
GADC5759OtherRAILROAD MEDICARE GROUP #
VAC09317Medicare ID - Type UnspecifiedGROUP #