Provider Demographics
NPI:1780621474
Name:TIDEWATER ANESTHESIA ASSOCIATES, PA
Entity type:Organization
Organization Name:TIDEWATER ANESTHESIA ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEINERT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:717-413-4756
Mailing Address - Street 1:PO BOX 1208
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-8924
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:219 S. WASHINGTON ST.
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-0712
Practice Address - Country:US
Practice Address - Phone:410-822-1000
Practice Address - Fax:410-819-0712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
367500000X
MDD0021319207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD155221000Medicaid
MD155221000Medicaid
MDA024Medicare ID - Type Unspecified