Basic Information
Provider Information | |||||||||
NPI: | 1518918754 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TIDAL EMEGENCY PHYSICIANS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 232 LAKESIDE DR | ||||||||
Address2: |   | ||||||||
City: | HORSHAM | ||||||||
State: | PA | ||||||||
PostalCode: | 190442319 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8002478060 | ||||||||
FaxNumber: | 2159572875 | ||||||||
Practice Location | |||||||||
Address1: | 1517 RICHMOND AVE | ||||||||
Address2: |   | ||||||||
City: | POINT PLEASANT BEACH | ||||||||
State: | NJ | ||||||||
PostalCode: | 087423056 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7322956377 | ||||||||
FaxNumber: | 7322068241 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/12/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HARRIS | ||||||||
AuthorizedOfficialFirstName: | RUSSELL | ||||||||
AuthorizedOfficialMiddleName: | H. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT/ CEO | ||||||||
AuthorizedOfficialTelephone: | 7322956377 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
No ID Information.