Provider Demographics
NPI:1487800876
Name:HARBOUR SPORTS MEDICINE
Entity type:Organization
Organization Name:HARBOUR SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ARTHUR
Authorized Official - Middle Name:W
Authorized Official - Last Name:WARDELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-215-1400
Mailing Address - Street 1:5818 HARBOUR VIEW BLVD # D
Mailing Address - Street 2:SUITE 150
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-3315
Mailing Address - Country:US
Mailing Address - Phone:757-215-1400
Mailing Address - Fax:757-215-1410
Practice Address - Street 1:5818 HARBOUR VIEW BLVD # D
Practice Address - Street 2:SUITE 150
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-3315
Practice Address - Country:US
Practice Address - Phone:757-215-1400
Practice Address - Fax:757-215-1410
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WARDELL ORTHOPAEDICS, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010321207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010080533Medicaid
VA1548289796OtherNPI
VA1548289796OtherNPI