Organization
COLON RECTAL SURGERY OF TIDEWATER, P.C.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JEFFREY STEPHEN WOLF M.D. (PRESIDENT)
(757) 484-9653
Entity
Organization
Contact information
Practice address
3235 ACADEMY AVE, SUITE 100, PORTSMOUTH, VA 23703-3200
(757) 484-9653
(757) 484-9662
Mailing address
3235 ACADEMY AVE, SUITE 100, PORTSMOUTH, VA 23703-3200
(757) 484-9653
(757) 484-9662
Taxonomy
Speciality
Code
Description
License number
State
208C00000X
Colon & Rectal Surgery Physician
Primary
0101031444
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
005841232
—
VA
01
—
072337
BC/BS
VA
01
—
200136
OPTIMA
VA
01
—
292832
MAMSI
VA
05
—
890528E
—
NC
Enumeration date
08/05/2006
Last updated
09/14/2011
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