Provider Demographics
NPI:1619043551
Name:NEUROLOGY CONSULTANTS OF TIDEWATER, PLLC
Entity type:Organization
Organization Name:NEUROLOGY CONSULTANTS OF TIDEWATER, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:C
Authorized Official - Last Name:VAN FOSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-226-0680
Mailing Address - Street 1:6161 KEMPSVILLE CIR
Mailing Address - Street 2:SUITE 315
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-3932
Mailing Address - Country:US
Mailing Address - Phone:757-461-5400
Mailing Address - Fax:757-461-3305
Practice Address - Street 1:6161 KEMPSVILLE CIR
Practice Address - Street 2:SUITE 315
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-3932
Practice Address - Country:US
Practice Address - Phone:757-461-5400
Practice Address - Fax:757-461-3305
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEUROLOGY CONSULTANTS OF TIDEWATER, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-24
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05869Medicare PIN