Provider Demographics
NPI:1033136841
Name:EMERGENCY PHYSICIANS OF TIDEWATER
Entity Type:Organization
Organization Name:EMERGENCY PHYSICIANS OF TIDEWATER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RITA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOSLET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-470-5810
Mailing Address - Street 1:6379 CENTER DR
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-4102
Mailing Address - Country:US
Mailing Address - Phone:757-467-4200
Mailing Address - Fax:
Practice Address - Street 1:6379 CENTER DR
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-4102
Practice Address - Country:US
Practice Address - Phone:757-467-4200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC01341Medicare PIN
VAC03047Medicare PIN
VAC02518Medicare PIN
VAC01707Medicare PIN