Healthcare Provider Details

I. General information

NPI: 1568236859
Provider Name (Legal Business Name): TIDEWATER PHYSICIANS MULTISPECIALTY GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2023
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4421 VIRGINIA BEACH BLVD STE 114
VA BEACH VA
23462-3114
US

IV. Provider business mailing address

860 OMNI BLVD STE 128
NEWPORT NEWS VA
23606-4483
US

V. Phone/Fax

Practice location:
  • Phone: 757-963-7676
  • Fax: 757-937-0104
Mailing address:
  • Phone: 757-232-8769
  • Fax: 757-232-8875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

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