Provider Demographics
NPI:1447201744
Name:VIRGINIA EM-I MEDICAL SERVICES, PC
Entity Type:Organization
Organization Name:VIRGINIA EM-I MEDICAL SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BOYD
Authorized Official - Middle Name:R
Authorized Official - Last Name:WICKIZER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-862-5680
Mailing Address - Street 1:100 WITMER RD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:HORSHAM
Mailing Address - State:PA
Mailing Address - Zip Code:19044-2211
Mailing Address - Country:US
Mailing Address - Phone:215-442-5021
Mailing Address - Fax:215-957-2875
Practice Address - Street 1:801 S ADAMS ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-5149
Practice Address - Country:US
Practice Address - Phone:804-862-5680
Practice Address - Fax:804-862-5698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA=========OtherTRICARE
VA=========OtherTRICARE
VAC06520Medicare PIN