Provider Demographics
NPI:1851488167
Name:EMERGENCY PHYSICIAN OF TIDEWATER
Entity type:Organization
Organization Name:EMERGENCY PHYSICIAN OF TIDEWATER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:AKSEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KEKLIK
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:757-410-8879
Mailing Address - Street 1:309 DOWNING DR
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23322-8703
Mailing Address - Country:US
Mailing Address - Phone:757-410-8879
Mailing Address - Fax:
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:2006-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001528282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital