1003407164 NPI number — TIDEWATER ANESTHESIA ASSOCIATES

Table of content: MS. SOPHIA WALTERS LICENSED OPTICIAN (NPI 1144044934)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003407164 NPI number — TIDEWATER ANESTHESIA ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIDEWATER ANESTHESIA ASSOCIATES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003407164
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/07/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1208
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EASTON
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21601-8924
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
219 S WASHINGTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EASTON
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21601-2913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-310-8576
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/01/2021

Additional Information

Authorized Official

Authorized Official Last Name:
KLEINERT
Authorized Official First Name:
BRADLEY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
717-413-4756

Provider Taxonomy Codes

  • Taxonomy code: 367500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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