Healthcare Provider Details

I. General information

NPI: 1316790512
Provider Name (Legal Business Name): TIDEWATER PHYSICIANS MULTISPECIALTY GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2024
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5424 DISCOVERY PARK BOULEVARD BUILDING A, SUITE 101 BUILDING A, SUITE 101
WILLIAMSBURG VA
23322
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 757-707-3505
  • Fax:
Mailing address:
  • Phone: 757-232-8769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CECILIA C QUINTERO
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 757-964-8739