Healthcare Provider Details

I. General information

NPI: 1023972551
Provider Name (Legal Business Name): TIDEWATER PHYSICIANS MULTISPECIALTY GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/10/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5424 DISCOVERY PARK BOULEVARD BUILDING B STE 203
WILLIAMSBURG VA
23188
US

IV. Provider business mailing address

860 OMNI BLVD STE 8
NEWPORT NEWS VA
23606-4434
US

V. Phone/Fax

Practice location:
  • Phone: 757-345-6223
  • Fax:
Mailing address:
  • Phone: 757-964-8739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State

VIII. Authorized Official

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