Provider Demographics
NPI:1790794022
Name:COLON RECTAL SURGERY OF TIDEWATER, P.C.
Entity Type:Organization
Organization Name:COLON RECTAL SURGERY OF TIDEWATER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:WOLF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-484-9653
Mailing Address - Street 1:3235 ACADEMY AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-3200
Mailing Address - Country:US
Mailing Address - Phone:757-484-9653
Mailing Address - Fax:757-484-9662
Practice Address - Street 1:3235 ACADEMY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703-3200
Practice Address - Country:US
Practice Address - Phone:757-484-9653
Practice Address - Fax:757-484-9662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101031444208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005841232Medicaid
VA072337OtherBC/BS
VA200136OtherOPTIMA
VA292832OtherMAMSI
NC890528EMedicaid
VA00V712C97Medicare ID - Type Unspecified
NC890528EMedicaid
VA005841232Medicaid
NC2317306Medicare PIN