Healthcare Provider Details

I. General information

NPI: 1285439281
Provider Name (Legal Business Name): TIDEWATER ANESTHESIA ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2025
Last Update Date: 02/14/2025
Certification Date: 02/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BROWN ST
CHESTERTOWN MD
21620-1435
US

IV. Provider business mailing address

PO BOX 1208
EASTON MD
21601-8924
US

V. Phone/Fax

Practice location:
  • Phone: 410-778-3300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: BRADLEY KLEINERT
Title or Position: PRESIDENT
Credential: DO
Phone: 717-413-4756