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General NPI Number Information
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NPI Number | 1568236859
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Entity Type | Organization
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Legal Business Name | TIDEWATER PHYSICIANS MULTISPECIALTY GROUP PC
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Dates
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Enumeration Date | 11/08/2023
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Last Update Date | 05/07/2025
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Provider Practice Location Address
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Address Line | 4421 VIRGINIA BEACH BLVD STE 114
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City | VA BEACH
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State | VA
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Zip | 23462-3114
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Country | US
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Telephone | 757-963-7676
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Fax | 757-937-0104
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Provider Business Mailing Address
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Address Line | 860 OMNI BLVD STE 128
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City | NEWPORT NEWS
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State | VA
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Zip | 23606-4483
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Country | US
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Telephone | 757-232-8769
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Fax | 757-232-8875
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Authorized Official
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Title or Position | CREDENTIALING MANAGER
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Name | ANGELA A WALKER
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Credential |
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Telephone | 757-232-8769
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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