1851488167 NPI number — EMERGENCY PHYSICIAN OF TIDEWATER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851488167 NPI number — EMERGENCY PHYSICIAN OF TIDEWATER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EMERGENCY PHYSICIAN OF TIDEWATER
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:
1851488167
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
309 DOWNING DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHESAPEAKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23322-8703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-410-8879
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4092 FOXWOOD DR
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
VIRGINIA BEACH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23462-5225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-467-4200
Provider Business Practice Location Address Fax Number:
757-467-4173
Provider Enumeration Date:
10/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KEKLIK
Authorized Official First Name:
AKSEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN ASSISTANT
Authorized Official Telephone Number:
757-410-8879

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  0110001528 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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