Healthcare Provider Details

I. General information

NPI: 1326428129
Provider Name (Legal Business Name): TIDEWATER PHYSICIANS MULTISPECIALTY GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2015
Last Update Date: 11/09/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 OMNI BLVD STE 401
NEWPORT NEWS VA
23606-4430
US

IV. Provider business mailing address

11761 ROCK LANDING DR STE 8
NEWPORT NEWS VA
23606-4235
US

V. Phone/Fax

Practice location:
  • Phone: 757-232-8764
  • Fax:
Mailing address:
  • Phone: 757-232-8769
  • Fax: 757-232-8875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701001988
License Number StateVA

VIII. Authorized Official

Name: ANGELA WALKER
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 757-232-8769