Healthcare Provider Details

I. General information

NPI: 1649222407
Provider Name (Legal Business Name): TIDAL EMERGENCY PHYSICIANS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 12/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1945 CORLIES AVE
NEPTUNE NJ
07753-4859
US

IV. Provider business mailing address

13737 NOEL RD STE 1600
DALLAS TX
75240-1331
US

V. Phone/Fax

Practice location:
  • Phone: 732-776-4203
  • Fax:
Mailing address:
  • Phone: 469-401-2386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RUSSELL H. HARRIS,
Title or Position: PRESIDENT
Credential: MD
Phone: 469-401-2386