Provider Demographics
NPI:1497074827
Name:PENINSULA ORTHOPAEDIC GROUP, PC
Entity Type:Organization
Organization Name:PENINSULA ORTHOPAEDIC GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:REID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-870-0699
Mailing Address - Street 1:304 MARCELLA RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-2578
Mailing Address - Country:US
Mailing Address - Phone:757-864-8040
Mailing Address - Fax:757-864-0848
Practice Address - Street 1:304 MARCELLA RD
Practice Address - Street 2:SUITE B
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2578
Practice Address - Country:US
Practice Address - Phone:757-864-0840
Practice Address - Fax:757-864-0848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-25
Last Update Date:2013-06-07
Deactivation Date:2013-05-28
Deactivation Code:
Reactivation Date:2013-06-07
Provider Licenses
StateLicense IDTaxonomies
VA0101036538207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty