Healthcare Provider Details

I. General information

NPI: 1225058548
Provider Name (Legal Business Name): TIDEWATER ORTHOPAEDIC ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 03/22/2024
Certification Date: 03/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 ENTERPRISE PKWY STE 900
HAMPTON VA
23666-6250
US

IV. Provider business mailing address

901 ENTERPRISE PARKWAY SUITE 900
HAMPTON VA
23666
US

V. Phone/Fax

Practice location:
  • Phone: 757-827-2480
  • Fax: 757-827-2566
Mailing address:
  • Phone: 757-827-2480
  • Fax: 757-282-5848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number78013
License Number StateVA

VIII. Authorized Official

Name: STACEY TANNER BELL
Title or Position: CEO
Credential:
Phone: 757-827-2480