Healthcare Provider Details

I. General information

NPI: 1871558270
Provider Name (Legal Business Name): TIDEWATER PAIN MANAGEMENT PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 04/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4125 IRONBOUND ROAD SUITE 101
WILLIAMSBURG VA
23188-2631
US

IV. Provider business mailing address

4125 IRONBOUND ROAD SUITE 101
WILLIAMSBURG VA
23188-2631
US

V. Phone/Fax

Practice location:
  • Phone: 757-258-2561
  • Fax: 757-258-5936
Mailing address:
  • Phone: 757-258-2561
  • Fax: 757-258-5936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number0102037017
License Number StateVA

VIII. Authorized Official

Name: DR. MARK WESLEY NEWMAN
Title or Position: PRESIDENT
Credential: DO
Phone: 757-258-2561