Provider Demographics
NPI:1740549302
Name:HAMPTON ROADS ORTHOPAEDIC & SPORTS MEDICINE LLC
Entity type:Organization
Organization Name:HAMPTON ROADS ORTHOPAEDIC & SPORTS MEDICINE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF INFORMATION OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-873-1554
Mailing Address - Street 1:732 THIMBLE SHOALS BLVD
Mailing Address - Street 2:SUITE 803
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4218
Mailing Address - Country:US
Mailing Address - Phone:757-933-8888
Mailing Address - Fax:757-806-6320
Practice Address - Street 1:730 THIMBLE SHOALS BLVD
Practice Address - Street 2:SUITE 130
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4562
Practice Address - Country:US
Practice Address - Phone:757-873-1554
Practice Address - Fax:757-873-3239
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HAMPTON ROADS ORTHOPAEDIC & SPORTS MEDICINE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-16
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05504Medicare PIN