Provider Demographics
NPI:1669852372
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 1:1620 C LIVE OAK STREET
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 1:3106 ARENDELL STREET
Practice Address - Street 2:
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-3202
Practice Address - Country:US
Practice Address - Phone:252-808-2500
Practice Address - Fax:252-808-2501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-08
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30580207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty