Provider Demographics
NPI:1851530851
Name:TIDEWATER PHYSICIANS MULTISPECIALTY GROUP
Entity type:Organization
Organization Name:TIDEWATER PHYSICIANS MULTISPECIALTY GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CECILIA
Authorized Official - Middle Name:
Authorized Official - Last Name:QUINTERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-964-8739
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:757-964-8739
Mailing Address - Fax:
Practice Address - Street 1:5424 DISCOVERY PARK BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-2862
Practice Address - Country:US
Practice Address - Phone:757-345-5870
Practice Address - Fax:757-345-6927
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TIDEWATER PHYSICIANS MULTISPECIALTY GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-13
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
1089360006Medicare NSC