Healthcare Provider Details

I. General information

NPI: 1346613262
Provider Name (Legal Business Name): BRIDGEWATER EMERGENCY PHYSICIANS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2015
Last Update Date: 11/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MAR WALT DR
FT WALTON BCH FL
32547-6708
US

IV. Provider business mailing address

PO BOX 80053
PHILADELPHIA PA
19101-0053
US

V. Phone/Fax

Practice location:
  • Phone: 469-401-2386
  • Fax:
Mailing address:
  • Phone: 469-401-2386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: GREGORY J. BYRNE, M.D.
Title or Position: OFFICER
Credential:
Phone: 469-401-2386