Provider Demographics
NPI:1518154947
Name:EMERGENCY PHYSICIANS OF TIDEWATER, PC
Entity Type:Organization
Organization Name:EMERGENCY PHYSICIANS OF TIDEWATER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:HUNDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-464-0029
Mailing Address - Street 1:PO BOX 7549
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-0549
Mailing Address - Country:US
Mailing Address - Phone:757-686-3515
Mailing Address - Fax:757-686-0541
Practice Address - Street 1:4092 FOXWOOD DR
Practice Address - Street 2:SUITE 101
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-5225
Practice Address - Country:US
Practice Address - Phone:757-467-4200
Practice Address - Fax:757-467-4173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC01341Medicare PIN