Healthcare Provider Details

I. General information

NPI: 1891375085
Provider Name (Legal Business Name): EMILY ROSE EGRESS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2021
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4374 NEW TOWN AVE STE 202
WILLIAMSBURG VA
23188-2865
US

IV. Provider business mailing address

4374 NEW TOWN AVE STE 202
WILLIAMSBURG VA
23188-2865
US

V. Phone/Fax

Practice location:
  • Phone: 757-984-6040
  • Fax:
Mailing address:
  • Phone: 757-984-6040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101282496
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: