NPIMap

Organization Active NPI

Tidewater Physical Therapy, LLC

Doing business as Pivot Physical Therapy of Virginia

  • Physical Therapist
  • Virginia Beach, VA
National Provider Identifier
1083133268
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
Doing business as
Pivot Physical Therapy of Virginia
Practice address
4624 Pembroke Blvd Ste 101
Virginia Beach, VA 23455-6450
Phone
(757) 460-3363
Fax
(757) 460-1809
NPI assigned
Sep 19, 2017
Last updated
Nov 25, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 25, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Tasheda Broughton, PESC
Title
Manager, Credentialing
Phone
(252) 248-3313

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physical Therapist 225100000X VA Primary

Addresses

Primary practice location

4624 Pembroke Blvd Ste 101
Virginia Beach, VA 23455-6450

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
C05954OtherVAGROUP MEDICARE PTAN

Other names 1

  • Pivot Physical Therapy of Virginia Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Tidewater Physical Therapy LLC28 organizations share this tax ID, including this one

Other organizations with this tax ID 27

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

View all 27

Practitioners & affiliated clinicians

Practitioners 46

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 46

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1505779200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1732492800000",
    "number": "1083133268",
    "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": "4624 PEMBROKE BLVD STE 101",
            "city": "VIRGINIA BEACH",
            "state": "VA",
            "postal_code": "234556450",
            "telephone_number": "757-460-3363",
            "fax_number": "757-460-1809"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TIDEWATER PHYSICAL THERAPY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-09-19",
        "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": "MANAGER, CREDENTIALING",
        "authorized_official_telephone_number": "252-248-3313",
        "authorized_official_credential": "PESC"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "VA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GROUP MEDICARE PTAN",
            "identifier": "C05954",
            "state": "VA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Pivot Physical Therapy of Virginia",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Pivot Physical Therapy of Virginia",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Virginia Beach, 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.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.