MEDICARE: TIDAL EMEGENCY PHYSICIANS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician

General Provider Information

NPI Number	:	1518918754
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIDAL EMEGENCY PHYSICIANS

Provider Business Mailing Address
First Line	:	232 LAKESIDE DR
Second Line	:
City	:	HORSHAM
State	:	PA
Zip	:	19044-2319
Country	:	US
Telephone Number	:	800-247-8060
Fax Number	:	215-957-2875

Provider Business Practice Location Address
First Line	:	1517 RICHMOND AVE
Second Line	:
City	:	POINT PLEASANT BEACH
State	:	NJ
Zip	:	08742-3056
Country	:	US
Telephone Number	:	732-295-6377
Fax Number	:	732-206-8241

Authorized Official
Title or Position	:	PRESIDENT/ CEO
Name	:	DR. RUSSELL H. HARRIS
Credential	:	MD
Telephone Number	:	732-295-6377

Provider Enumeration Date	:	05/12/2006
Last Update Date	:	08/22/2020

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