| Tidewater Mobile Medicine, Pllc | |
|
3520 High St Ste 100 Portsmouth VA 23707-3126 | |
| (757) 977-9675 | |
| (757) 483-8099 |
| Full Name | Tidewater Mobile Medicine, Pllc |
|---|---|
| Speciality | Family Medicine |
| Location | 3520 High St Ste 100, Portsmouth, Virginia |
| Authorized Official Name and Position | Jimmy Cooper (CEO/OWNER) |
| Authorized Official Contact | 7579779675 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Tidewater Mobile Medicine, Pllc 3520 High St Ste 100 Portsmouth VA 23707-3126 Ph: (757) 977-9675 | Tidewater Mobile Medicine, Pllc 3520 High St Ste 100 Portsmouth VA 23707-3126 Ph: (757) 977-9675 |
| NPI Number | 1225527351 |
|---|---|
| Provider Enumeration Date | 05/03/2018 |
| Last Update Date | 01/21/2022 |
| Certification Date | 01/21/2022 |
| Medicare PECOS PAC ID | 9739435066 |
|---|---|
| Medicare Enrollment ID | O20180628002808 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1225527351 | NPI | - | NPPES |
| Provider Name | Jimmy L Cooper |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1205123171 PECOS PAC ID: 9234302795 Enrollment ID: I20111027000602 |
| Provider Name | Shauna Speede Thomas |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1447721881 PECOS PAC ID: 4981130770 Enrollment ID: I20241203003329 |
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