Provider Demographics
NPI:1730214248
Name:TIDEWATER FAMILY MEDICAL CARE, PC
Entity type:Organization
Organization Name:TIDEWATER FAMILY MEDICAL CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:PICCIONI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:757-495-0606
Mailing Address - Street 1:516 INNOVATION DR
Mailing Address - Street 2:STE. 103
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-3847
Mailing Address - Country:US
Mailing Address - Phone:757-495-0606
Mailing Address - Fax:757-495-0952
Practice Address - Street 1:516 INNOVATION DR
Practice Address - Street 2:STE 103
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-3847
Practice Address - Country:US
Practice Address - Phone:757-495-0606
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102037087207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10139414Medicaid
VA131473OtherOPTIMA ID
VA172725OtherANTHEM BCBS ID
VA10139414Medicaid