Provider Demographics
NPI:1649399650
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:757-827-2566
Practice Address - Street 1:4037 IRONBOUND RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-2507
Practice Address - Country:US
Practice Address - Phone:757-206-1004
Practice Address - Fax:757-645-3965
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
VA207X00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC01502Medicare PIN
VA6519340001Medicare NSC