Healthcare Provider Details

I. General information

NPI: 1003407164
Provider Name (Legal Business Name): TIDEWATER ANESTHESIA ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2021
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 S WASHINGTON ST
EASTON MD
21601-2913
US

IV. Provider business mailing address

PO BOX 1208
EASTON MD
21601-8924
US

V. Phone/Fax

Practice location:
  • Phone: 410-310-8576
  • 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 A KLEINERT
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 717-413-4756