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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1568236859
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	:	4421 VIRGINIA BEACH BLVD STE 114
Second Line	:
City	:	VA BEACH
State	:	VA
Zip	:	23462-3114
Country	:	US
Telephone Number	:	757-963-7676
Fax Number	:	757-937-0104

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

Provider Enumeration Date	:	11/08/2023
Last Update Date	:	03/11/2026

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