Provider Demographics
NPI:1306590450
Name:OBSERVATION PHYSICIANS OF TIDEWATER
Entity type:Organization
Organization Name:OBSERVATION PHYSICIANS OF TIDEWATER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:K
Authorized Official - Last Name:BONADIES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-748-4500
Mailing Address - Street 1:6379 CENTER DR
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-4102
Mailing Address - Country:US
Mailing Address - Phone:757-467-4200
Mailing Address - Fax:
Practice Address - Street 1:830 KEMPSVILLE RD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-3920
Practice Address - Country:US
Practice Address - Phone:757-261-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EMERGENCY PHYSICIANS OF TIDEWATER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-02-08
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty