Provider Demographics
NPI:1316790512
Name:TIDEWATER PHYSICIANS MULTISPECIALTY GROUP
Entity type:Organization
Organization Name:TIDEWATER PHYSICIANS MULTISPECIALTY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-504-0924
Mailing Address - Street 1:860 OMNI BLVD STE 128
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4483
Mailing Address - Country:US
Mailing Address - Phone:757-232-8769
Mailing Address - Fax:
Practice Address - Street 1:5424 DISCOVERY PARK BOULEVARD BUILDING A, SUITE 101
Practice Address - Street 2:BUILDING A, SUITE 101
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23322
Practice Address - Country:US
Practice Address - Phone:757-707-3505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical