Provider Demographics
NPI:1871558270
Name:TIDEWATER PAIN MANAGEMENT PC
Entity type:Organization
Organization Name:TIDEWATER PAIN MANAGEMENT PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:WESLEY
Authorized Official - Last Name:NEWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:757-258-2561
Mailing Address - Street 1:4125 IRONBOUND ROAD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-2631
Mailing Address - Country:US
Mailing Address - Phone:757-258-2561
Mailing Address - Fax:757-258-5936
Practice Address - Street 1:4125 IRONBOUND ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-2631
Practice Address - Country:US
Practice Address - Phone:757-258-2561
Practice Address - Fax:757-258-5936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-19
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102037017208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA322590OtherANTHEM BCBS
E29953Medicare UPIN