Healthcare Provider Details

I. General information

NPI: 1487800876
Provider Name (Legal Business Name): HARBOUR SPORTS MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2008
Last Update Date: 08/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5818 HARBOUR VIEW BLVD # D SUITE 150
SUFFOLK VA
23435-3315
US

IV. Provider business mailing address

5818 HARBOUR VIEW BLVD # D SUITE 150
SUFFOLK VA
23435-3315
US

V. Phone/Fax

Practice location:
  • Phone: 757-215-1400
  • Fax: 757-215-1410
Mailing address:
  • Phone: 757-215-1400
  • Fax: 757-215-1410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number01010321
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number01010321
License Number StateVA

VIII. Authorized Official

Name: DR. ARTHUR W WARDELL
Title or Position: PRESIDENT, OWNER
Credential: M.D.
Phone: 757-215-1400