Provider Demographics
NPI:1154724813
Name:HAMPTON ROADS ORTHOPAEDIC & SPORTS MEDICINE LLC
Entity type:Organization
Organization Name:HAMPTON ROADS ORTHOPAEDIC & SPORTS MEDICINE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF INFORMATION OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-327-0103
Mailing Address - Street 1:730 THIMBLE SHOALS BLVD STE 130
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4562
Mailing Address - Country:US
Mailing Address - Phone:757-873-1554
Mailing Address - Fax:757-873-3239
Practice Address - Street 1:4030 GEORGE WASHINGTON MEM HWY STE B
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:VA
Practice Address - Zip Code:23692-2619
Practice Address - Country:US
Practice Address - Phone:757-898-5500
Practice Address - Fax:757-898-5500
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HAMPTON ROADS ORTHOPAEDIC & SPORTS MEDICINE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-10-08
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05504Medicare PIN