Healthcare Provider Details

I. General information

NPI: 1649399650
Provider Name (Legal Business Name): TIDEWATER ORTHOPAEDIC ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 03/22/2024
Certification Date: 03/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4037 IRONBOUND RD
WILLIAMSBURG VA
23188-2507
US

IV. Provider business mailing address

901 ENTERPRISE PARKWAY SUITE 900
HAMPTON VA
23666
US

V. Phone/Fax

Practice location:
  • Phone: 757-206-1004
  • Fax: 757-645-3965
Mailing address:
  • Phone: 757-827-2480
  • Fax: 757-827-2566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

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