Healthcare Provider Details

I. General information

NPI: 1740549302
Provider Name (Legal Business Name): HAMPTON ROADS ORTHOPAEDIC & SPORTS MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2012
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

732 THIMBLE SHOALS BLVD STE 803
NEWPORT NEWS VA
23606-4218
US

IV. Provider business mailing address

730 THIMBLE SHOALS BLVD STE 130
NEWPORT NEWS VA
23606-4562
US

V. Phone/Fax

Practice location:
  • Phone: 757-873-1554
  • Fax: 757-873-3239
Mailing address:
  • Phone: 757-933-8888
  • Fax: 757-806-6320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: WENDY JACKSON
Title or Position: CHIEF INFORMATION OFFICER
Credential:
Phone: 757-873-1554