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General NPI Number Information
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NPI Number | 1851488167
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Entity Type | Organization
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Legal Business Name | EMERGENCY PHYSICIAN OF TIDEWATER
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Dates
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Enumeration Date | 10/06/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 4092 FOXWOOD DR SUITE 101
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City | VIRGINIA BEACH
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State | VA
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Zip | 23462-5225
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Country | US
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Telephone | 757-467-4200
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Fax | 757-467-4173
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Provider Business Mailing Address
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Address Line | 309 DOWNING DR
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City | CHESAPEAKE
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State | VA
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Zip | 23322-8703
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Country | US
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Telephone | 757-410-8879
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN ASSISTANT
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Name | MR. AKSEL KEKLIK
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Credential | PA-C
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Telephone | 757-410-8879
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 282N00000X
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Taxonomy Name | General Acute Care Hospital
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License Number | 0110001528
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License Number State | VA
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