Healthcare Provider Details

I. General information

NPI: 1003730169
Provider Name (Legal Business Name): OPEN WATER MEDICAL, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2026
Last Update Date: 08/10/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

458 HWY 70 EAST
SEA LEVEL NC
28577
US

IV. Provider business mailing address

1620C LIVE OAK ST
BEAUFORT NC
28516-1583
US

V. Phone/Fax

Practice location:
  • Phone: 252-728-5737
  • Fax:
Mailing address:
  • Phone: 252-728-5737
  • Fax: 252-723-5739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: SAMUEL WILLIS
Title or Position: COO
Credential:
Phone: 252-723-7234