MEDICARE: OPEN WATER MEDICAL, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	30580	NC

General Provider Information

NPI Number	:	1669852372
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPEN WATER MEDICAL, PA

Provider Business Mailing Address
First Line	:	1620 C LIVE OAK STREET
Second Line	:
City	:	BEAUFORT
State	:	NC
Zip	:	28516-1583
Country	:	US
Telephone Number	:	252-728-5737
Fax Number	:	252-728-5739

Provider Business Practice Location Address
First Line	:	3106 ARENDELL STREET
Second Line	:
City	:	MOREHEAD CITY
State	:	NC
Zip	:	28557-3202
Country	:	US
Telephone Number	:	252-808-2500
Fax Number	:	252-808-2501

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	TISHA RAE SMITH
Credential	:
Telephone Number	:	252-728-5737

Provider Enumeration Date	:	06/08/2015
Last Update Date	:	02/24/2022

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