Provider Demographics
NPI:1609969641
Name:PENINSULA ORTHOPAEDIC GROUP, PC
Entity Type:Organization
Organization Name:PENINSULA ORTHOPAEDIC GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:REID
Authorized Official - Suffix:
Authorized Official - Credentials:MD
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:757-870-0699
Mailing Address - Fax:
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:757-870-0699
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2013-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101036538207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAANTHEMOther256737