MEDICARE: TIDEWATER PHYSICIANS MULTISPECIALTY GROUP

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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1851530851
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIDEWATER PHYSICIANS MULTISPECIALTY GROUP

Provider Business Mailing Address
First Line	:	860 OMNI BLVD STE 128
Second Line	:
City	:	NEWPORT NEWS
State	:	VA
Zip	:	23606-4483
Country	:	US
Telephone Number	:	757-964-8739
Fax Number	:

Provider Business Practice Location Address
First Line	:	5424 DISCOVERY PARK BLVD
Second Line	:	SUITE 105
City	:	WILLIAMSBURG
State	:	VA
Zip	:	23188-2862
Country	:	US
Telephone Number	:	757-345-5870
Fax Number	:	757-345-6927

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	CECILIA QUINTERO
Credential	:
Telephone Number	:	757-964-8739

Provider Enumeration Date	:	02/13/2009
Last Update Date	:	09/02/2025

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