Provider Demographics
NPI:1225058548
Name:TIDEWATER ORTHOPAEDIC ASSOCIATES INC
Entity Type:Organization
Organization Name:TIDEWATER ORTHOPAEDIC ASSOCIATES INC
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 PARKWAY
Mailing Address - Street 2:SUITE 900
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666
Mailing Address - Country:US
Mailing Address - Phone:757-827-2480
Mailing Address - Fax:757-282-5848
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:2006-07-20
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA78013207X00000X
261QP2000X, 261QX0100X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA64835OtherSENTARA THERAPY GROUP#
VA3001514667-0004Medicaid
VA453382OtherANTHEM GROUP NUMBER
VA192680OtherANTHEM OT GROUP#
CF1964OtherMEDICARE RR GROUP NUMBER
VA3001514667-0001Medicaid
VA3001514667-0005Medicaid
371277300OtherUS DEPT OF LABOR GROUP#
VA463139OtherANTHEM PT GROUP NUMBER
VA500002OtherSENTARA VENDER NUMBER