Provider Demographics
NPI:1609004571
Name:TIDEWATER PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:TIDEWATER PHYSICAL THERAPY, LLC
Other - Org Name:<UNAVAIL>
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:252-248-3313
Mailing Address - Fax:410-648-4878
Practice Address - Street 1:3510 ANDERSON HWY
Practice Address - Street 2:SUITE 2
Practice Address - City:POWHATAN
Practice Address - State:VA
Practice Address - Zip Code:23139
Practice Address - Country:US
Practice Address - Phone:804-598-2100
Practice Address - Fax:804-598-7624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-30
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA223951124OtherDEPT OF LABOR/ACS
VA1609004571OtherBCBS (PHYSICAL THERAPY)
VA1609004571OtherBCBS (OCCUPATIONAL THERAPY)
VA223951124OtherDEPT OF LABOR/ACS
VA223951124OtherDEPT OF LABOR/ACS
VAC05954Medicare PIN