Basic Information
| Provider Information | |||||||||
| NPI: | 1033136841 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EMERGENCY PHYSICIANS OF TIDEWATER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6379 CENTER DR | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235024102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574674200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6379 CENTER DR | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235024102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574674200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 08/02/2021 | ||||||||
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| AuthorizedOfficialLastName: | BOSLET | ||||||||
| AuthorizedOfficialFirstName: | RITA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7574705810 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.