Healthcare Provider Details

I. General information

NPI: 1851530851
Provider Name (Legal Business Name): TIDEWATER PHYSICIANS MULTISPECIALTY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2009
Last Update Date: 09/02/2025
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5424 DISCOVERY PARK BLVD SUITE 105
WILLIAMSBURG VA
23188-2862
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 757-345-5870
  • Fax: 757-345-6927
Mailing address:
  • Phone: 757-964-8739
  • Fax:

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