MEDICARE: TIDEWATER PHYSICIANS MULTISPECIALTY GROUP PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0002X	Clinic Pharmacy

General Provider Information

NPI Number	:	1023972551
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIDEWATER PHYSICIANS MULTISPECIALTY GROUP PC

Provider Business Mailing Address
First Line	:	860 OMNI BLVD STE 8
Second Line	:
City	:	NEWPORT NEWS
State	:	VA
Zip	:	23606-4434
Country	:	US
Telephone Number	:	757-964-8739
Fax Number	:

Provider Business Practice Location Address
First Line	:	5424 DISCOVERY PARK BOULEVARD BUILDING B STE 203
Second Line	:
City	:	WILLIAMSBURG
State	:	VA
Zip	:	23188
Country	:	US
Telephone Number	:	757-345-6223
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	CECILIA CRUTCHER QUINTERO
Credential	:
Telephone Number	:	757-964-8739

Provider Enumeration Date	:	12/10/2025
Last Update Date	:	12/10/2025

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