Provider Demographics
NPI:1699818237
Name:PHYSICIANS' SURGERY CENTER OF TIDEWATER, LLC
Entity type:Organization
Organization Name:PHYSICIANS' SURGERY CENTER OF TIDEWATER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:OCONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-376-7315
Mailing Address - Street 1:828 HEALTHY WAY
Mailing Address - Street 2:STE 115
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-7958
Mailing Address - Country:US
Mailing Address - Phone:757-495-8070
Mailing Address - Fax:757-495-8074
Practice Address - Street 1:828 HEALTHY WAY STE 115
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-7958
Practice Address - Country:US
Practice Address - Phone:757-495-8070
Practice Address - Fax:757-495-8074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAOH 708261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00426243OtherRAILROAD MEDICARE
VAP00426243OtherRAILROAD MEDICARE
192949771Medicare PIN