Provider Demographics
NPI:1295822351
Name:PLASTIC SURGERY ASSOCIATES OF TIDEWATER, INC.
Entity type:Organization
Organization Name:PLASTIC SURGERY ASSOCIATES OF TIDEWATER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:MERRELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD,FACS
Authorized Official - Phone:757-673-6000
Mailing Address - Street 1:300 MEDICAL PKWY
Mailing Address - Street 2:SUITE 316
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-4985
Mailing Address - Country:US
Mailing Address - Phone:757-547-0047
Mailing Address - Fax:757-548-3370
Practice Address - Street 1:300 MEDICAL PKWY
Practice Address - Street 2:SUITE 316
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4985
Practice Address - Country:US
Practice Address - Phone:757-547-0047
Practice Address - Fax:757-548-3370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2012-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA05286935174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty