Organization
TIDEWATER MEDICAL SUPPLY, INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. KEITH ANTHONY DAVIES (PRESIDENT)
(757) 548-9999
Entity
Organization
Contact information
Practice address
525 BYRON ST, SUITE A, CHESAPEAKE, VA 23320-7967
(757) 548-9999
(757) 549-7752
Mailing address
525 BYRON ST, SUITE A, CHESAPEAKE, VA 23320-7967
(757) 548-9999
(757) 549-7752
Taxonomy
Speciality
Code
Description
License number
State
332BX2000X
Oxygen Equipment & Supplies (DME)
Primary
0206009115
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
009117920
—
VA
01
—
1258980001
MEDICARE PARTICIPATING PROVIDER ID # 1258980001 STATE VA PTAN #
VA
Enumeration date
09/17/2006
Last updated
03/11/2010
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