Organization
LONG TERM CARE OF TIDEWATER PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JAYNE WALTER (CREDENTIALING)
(757) 917-5356
Entity
Organization
Contact information
Practice address
6160 KEMPSVILLE CIR STE 325A, NORFOLK, VA 23502-3933
(757) 917-5356
(757) 917-5141
Mailing address
110 KINGSLEY LN STE 312, NORFOLK, VA 23505-4618
(757) 917-5356
(757) 917-5141
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
—
—
207RG0300X
Geriatric Medicine (Internal Medicine) Physician
—
—
207RN0300X
Nephrology Physician
—
—
2084P0800X
Psychiatry Physician
—
—
363L00000X
Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
CK3562
RAILROAD MEDICARE GROUP #
VA
Enumeration date
06/19/2006
Last updated
11/01/2019
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