Provider Demographics
NPI:1497490957
Name:OPEN WATER MEDICAL, PA
Entity Type:Organization
Organization Name:OPEN WATER MEDICAL, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TISHA
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-728-5737
Mailing Address - Street 1:1620C LIVE OAK ST
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:NC
Mailing Address - Zip Code:28516-1583
Mailing Address - Country:US
Mailing Address - Phone:252-728-5737
Mailing Address - Fax:252-728-5739
Practice Address - Street 1:11 OFFICE PARK DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-7326
Practice Address - Country:US
Practice Address - Phone:910-353-9906
Practice Address - Fax:910-353-4853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-29
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1750482493Medicaid