Provider Demographics
NPI:1982889408
Name:TIDEWATER PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:TIDEWATER PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER, CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:TASHEDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROUGHTON
Authorized Official - Suffix:
Authorized Official - Credentials:PESC
Authorized Official - Phone:252-248-3313
Mailing Address - Street 1:2122 YORK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1925
Mailing Address - Country:US
Mailing Address - Phone:252-248-3133
Mailing Address - Fax:410-648-4878
Practice Address - Street 1:7493 RIGHT FLANK RD
Practice Address - Street 2:SUITE 410
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-3846
Practice Address - Country:US
Practice Address - Phone:804-569-7091
Practice Address - Fax:804-569-7094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA342325OtherBCBS OCCUPATIONAL THERAPY
VA342327OtherBCBS PHYSICAL THERAPY
VA342325OtherBCBS OCCUPATIONAL THERAPY
VA=========045OtherTRICARE
VA342325OtherBCBS OCCUPATIONAL THERAPY