Provider Demographics
NPI:1154440170
Name:TIDEWATER ORTHOPAEDIC ASSOCIATES
Entity Type:Organization
Organization Name:TIDEWATER ORTHOPAEDIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:TANNER
Authorized Official - Last Name:BELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-827-2480
Mailing Address - Street 1:901 ENTERPRISE PKWY STE 900
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-6250
Mailing Address - Country:US
Mailing Address - Phone:757-827-2480
Mailing Address - Fax:757-299-9917
Practice Address - Street 1:901 ENTERPRISE PKWY STE 900
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-6250
Practice Address - Country:US
Practice Address - Phone:757-827-2480
Practice Address - Fax:757-827-2566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA030451174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty