Provider Demographics
NPI:1356542922
Name:TIDEWATER PODIATRY GROUP LTD
Entity type:Organization
Organization Name:TIDEWATER PODIATRY GROUP LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:TISCHLER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:757-481-6248
Mailing Address - Street 1:6161 KEMPSVILLE CIR
Mailing Address - Street 2:STE 230
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-3932
Mailing Address - Country:US
Mailing Address - Phone:757-481-6248
Mailing Address - Fax:
Practice Address - Street 1:6161 KEMPSVILLE CIR
Practice Address - Street 2:STE 230
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-3932
Practice Address - Country:US
Practice Address - Phone:757-481-6248
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAT21531Medicare UPIN
VAT21387Medicare UPIN
VA0767720001Medicare NSC
VAC01098Medicare PIN
VACC6300Medicare PIN