Tidewater Mobile Medicine, PLLC

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

Legal business name

TIDEWATER MOBILE MEDICINE, PLLC

Practice address

3520 High St Ste 100
Portsmouth, VA 23707-3126

Phone

(757) 977-9675

Fax

(757) 483-8099

NPI assigned

May 3, 2018

Organization subpart

Yes

Parent organization

TIDEWATER MOBILE MEDICINE PLLCAs reported in NPPES

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Jimmy Cooper Jr., DHA, FNP-CNPI 1205123171

Title

Ceo/Owner

Phone

(757) 977-9675

Specialties & licenses 5

Addresses

Other names 2

• Authentic Self Counseling Services Doing business as
• TMM Medical Group Doing business as

Medicare fee-for-service enrollment

Enrolled in VA

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Part of

Tidewater Mobile Medicine P

Locations

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Jimmy Cooper Jr., DHA, FNP-C

  • Family Nurse Practitioner
  • Portsmouth, VA
  • NPI 1205123171
  Medicare reassignment Care Compare group NPD Authorized official
• Precious Gillispie, FNP-BC

  • Family Nurse Practitioner
  • Hampton, VA
  • NPI 1568261840
  Medicare reassignment Care Compare group NPD
• Shauna Speede Thomas, FNP-BC

  • Family Nurse Practitioner
  • Portsmouth, VA
  • NPI 1447721881
  Medicare reassignment Care Compare group NPD
• Maisie Cowden, APRN

  • Family Medicine Physician
  • Portsmouth, VA
  • NPI 1164376752
  Medicare reassignment
• Shenell Cooper, MSW

  • Addiction (Substance Use Disorder) Counselor
  • Chesapeake, VA
  • NPI 1174114524
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1525305600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1642723200000",
    "number": "1225527351",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3520 HIGH ST STE 100",
            "city": "PORTSMOUTH",
            "state": "VA",
            "postal_code": "237073126",
            "telephone_number": "757-977-9675",
            "fax_number": "757-483-4099"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3520 HIGH ST STE 100",
            "city": "PORTSMOUTH",
            "state": "VA",
            "postal_code": "237073126",
            "telephone_number": "757-977-9675",
            "fax_number": "757-483-8099"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "3001 Churchland Blvd",
            "address_purpose": "LOCATION",
            "city": "Chesapeake",
            "state": "VA",
            "postal_code": "233215603",
            "country_code": "US",
            "telephone_number": "757-977-9675",
            "fax_number": "757-483-8099",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "TIDEWATER MOBILE MEDICINE, PLLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "TIDEWATER MOBILE MEDICINE PLLC",
        "enumeration_date": "2018-05-03",
        "last_updated": "2022-01-21",
        "certification_date": "2022-01-21",
        "status": "A",
        "authorized_official_last_name": "COOPER",
        "authorized_official_first_name": "JIMMY",
        "authorized_official_title_or_position": "CEO/OWNER",
        "authorized_official_telephone_number": "757-977-9675",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_name_suffix": "Jr.",
        "authorized_official_credential": "DHA, FNP-C"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker, Clinical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": "VA",
            "license": "46193",
            "primary": false
        },
        {
            "code": "343900000X",
            "taxonomy_group": "",
            "desc": "Non-emergency Medical Transport (VAN)",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Authentic Self Counseling Services",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "TMM Medical Group",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Tidewater Eye Centers
• Tidewater Eye Centers
• Tidewater Eye Centers PC
• Tidewater Medical Transport, Inc
• Tidewater Medspa PLLC
• Tidewater Neurologists Inc, PC
• Tidewater Pediatrics, P.C.
• Tidewater Regional Group Home Commission
• Denise M. Tidwell, RPH
• Jone Latice Tillman

• Family Medicine Physician in Portsmouth, VA
• Providers in Portsmouth, VA by specialty
• Family Medicine Physician in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 21, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.