Healthcare Provider Details

I. General information

NPI: 1790794022
Provider Name (Legal Business Name): COLON RECTAL SURGERY OF TIDEWATER, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 09/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3235 ACADEMY AVE SUITE 100
PORTSMOUTH VA
23703-3200
US

IV. Provider business mailing address

3235 ACADEMY AVE SUITE 100
PORTSMOUTH VA
23703-3200
US

V. Phone/Fax

Practice location:
  • Phone: 757-484-9653
  • Fax: 757-484-9662
Mailing address:
  • Phone: 757-484-9653
  • Fax: 757-484-9662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number0101031444
License Number StateVA

VIII. Authorized Official

Name: DR. JEFFREY STEPHEN WOLF
Title or Position: PRESIDENT
Credential: M.D.
Phone: 757-484-9653