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General NPI Number Information
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NPI Number | 1790794022
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Entity Type | Organization
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Legal Business Name | COLON RECTAL SURGERY OF TIDEWATER, P.C.
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Dates
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Enumeration Date | 08/05/2006
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Last Update Date | 09/14/2011
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Provider Practice Location Address
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Address Line | 3235 ACADEMY AVE SUITE 100
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City | PORTSMOUTH
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State | VA
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Zip | 23703-3200
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Country | US
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Telephone | 757-484-9653
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Fax | 757-484-9662
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Provider Business Mailing Address
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Address Line | 3235 ACADEMY AVE SUITE 100
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City | PORTSMOUTH
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State | VA
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Zip | 23703-3200
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Country | US
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Telephone | 757-484-9653
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Fax | 757-484-9662
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JEFFREY STEPHEN WOLF
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Credential | M.D.
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Telephone | 757-484-9653
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208C00000X
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Taxonomy Name | Colon & Rectal Surgery Physician
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License Number | 0101031444
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License Number State | VA
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