Provider Demographics
NPI:1902848294
Name:TIDEWATER PHYSICIANS MULTISPECIALTY GROUP PC
Entity type:Organization
Organization Name:TIDEWATER PHYSICIANS MULTISPECIALTY GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CECILIA
Authorized Official - Middle Name:C
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:757-232-8769
Mailing Address - Fax:757-232-8875
Practice Address - Street 1:860 OMNI BLVD STE 401
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4430
Practice Address - Country:US
Practice Address - Phone:757-232-8764
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 207RG0100X, 207V00000X, 207W00000X, 207X00000X, 2085R0202X, 208600000X, 208800000X, 291U00000X, 207Q00000X
VA182340975207RE0101X
VA223741512207RN0300X
VA229641543207RR0500X
VA0103300835213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VACA6708OtherRAILROAD MEDICARE
VAC03977Medicare PIN
VAC04137Medicare PIN
VA1089360006Medicare NSC
VAC04725Medicare PIN
VAC03522Medicare PIN
VAC03978Medicare PIN
VAC05438Medicare PIN
VAC08262Medicare PIN
VA690000041Medicare PIN
VAC05500Medicare PIN
VACA6708OtherRAILROAD MEDICARE
VAC04673Medicare PIN
VAC04738Medicare PIN