NPIMap

Organization Active NPI

Tidewater Physical Therapy, LLC

  • Physical Therapist
  • Richmond, VA
National Provider Identifier
1003114083
Registry record updated Nov 25, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physical TherapistTaxonomy code 225100000X
Legal business name
TIDEWATER PHYSICAL THERAPY, LLC
Practice address
4831 S Laburnum Ave
Richmond, VA 23231-2713
Phone
(804) 222-0746
Fax
(804) 222-0728
NPI assigned
Mar 1, 2011
Organization subpart
No

Authorized official

NPPES NPI Registry
Name
Tasheda Broughton, PESC
Title
Manger, Credentialing
Phone
(252) 248-3313

Other NPIs on the same Medicare enrollment 11

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Corporate family (same tax ID) 27

Organizations that report the same tax identification number in the National Provider Directory.

View all 27

Practitioners 11

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in VA

Medicare enrollment records 1

Medicare enrollment files
Enrollment IDStateProvider typePAC IDDetails
O20041019001029 VA Part B Supplier - Physical/Occupational Therapy Group in Private Practice 6406759281 Receives reassigned benefits from 379 practitioners
11 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment

National Provider Directory

National Provider Directory
Tax ID family
Tidewater Physical Therapy LLC (28 organizations share this tax ID)

Locations

927 Battlefield Blvd N
Ste 200
Chesapeake, VA 23320
Phone (757) 436-3350

771 Pilot House Dr
#A
Newport News, VA 23606
Phone (757) 873-2302

6161 Kempsville Cir
Ste 250
Norfolk, VA 23502
Phone (757) 893-9210

1745 Camelot Dr
Ste 100
Virginia Beach, VA 23454
Phone (757) 496-2300

Specialties & licenses 2

NPPES NPI Registry
Specialty (taxonomy)CodeLicenseStatePrimary
Physical TherapistGroup: 193200000X MULTI-SPECIALTY GROUP 225100000X VA Primary
Occupational TherapistGroup: 193200000X MULTI-SPECIALTY GROUP 225X00000X

Addresses

NPPES NPI Registry

Primary practice location

4831 S Laburnum Ave
Richmond, VA 23231-2713

Mailing address

2122 York Rd Ste 300
Oak Brook, IL 60523-1925
Phone (252) 248-3313

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Nov 25, 2024.

{
    "created_epoch": "1298937600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1732492800000",
    "number": "1003114083",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2122 YORK RD STE 300",
            "city": "OAK BROOK",
            "state": "IL",
            "postal_code": "605231925",
            "telephone_number": "252-248-3313",
            "fax_number": "410-678-4878"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4831 S LABURNUM AVE",
            "city": "RICHMOND",
            "state": "VA",
            "postal_code": "232312713",
            "telephone_number": "804-222-0746",
            "fax_number": "804-222-0728"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TIDEWATER PHYSICAL THERAPY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-03-01",
        "last_updated": "2024-11-25",
        "certification_date": "2024-11-25",
        "status": "A",
        "authorized_official_last_name": "BROUGHTON",
        "authorized_official_first_name": "TASHEDA",
        "authorized_official_title_or_position": "MANGER, CREDENTIALING",
        "authorized_official_telephone_number": "252-248-3313",
        "authorized_official_credential": "PESC"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physical Therapist",
            "state": "VA",
            "license": null,
            "primary": true
        },
        {
            "code": "225X00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Occupational Therapist",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Richmond, VA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 25, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.