Basic Information
| Provider Information | |||||||||
| NPI: | 1851488167 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EMERGENCY PHYSICIAN OF TIDEWATER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 309 DOWNING DR | ||||||||
| Address2: | |||||||||
| City: | CHESAPEAKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 233228703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574108879 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4092 FOXWOOD DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234625225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574674200 | ||||||||
| FaxNumber: | 7574674173 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KEKLIK | ||||||||
| AuthorizedOfficialFirstName: | AKSEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICIAN ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 7574108879 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PA-C | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 0110001528 | VA | Y | Hospitals | General Acute Care Hospital |
No ID Information.