Healthcare Provider Details

I. General information

NPI: 1477592608
Provider Name (Legal Business Name): VIRGINIA EM-I MEDICAL SERVICES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S ADAMS ST
PETERSBURG VA
23803-5149
US

IV. Provider business mailing address

2904 LEATHERWOOD WAY
MIDLOTHIAN VA
23113-1413
US

V. Phone/Fax

Practice location:
  • Phone: 804-862-5680
  • Fax:
Mailing address:
  • Phone: 804-378-6003
  • 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. BOYD R. WICKIZER
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 804-862-5680