NPIMap

Organization Active NPI

Tidewater Physical Therapy, LLC

  • Physical Therapist
  • Virginia Beach, VA
National Provider Identifier
1093172181
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
1745 Camelot Dr
Suite 100
Virginia Beach, VA 23454-2435
Phone
(757) 961-4800
Fax
(757) 961-0233
NPI assigned
Jan 21, 2016
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
Manger, Credentialing
Phone
(252) 248-3313

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Physical Therapist 225100000X NU Primary
Occupational Therapist 225X00000X NU

Addresses

Primary practice location

1745 Camelot Dr
Suite 100
Virginia Beach, VA 23454-2435

Mailing address

350 New Fidelity CT
Garner, NC 27529-2665
Phone (919) 258-2714

Other identifiers 1

IdentifierTypeStateIssuer
C05954OtherVAMEDICARE GROUP PTAN

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 43

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 43

NPI Registry JSON

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

{
    "created_epoch": "1453334400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1732492800000",
    "number": "1093172181",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "350 NEW FIDELITY CT",
            "city": "GARNER",
            "state": "NC",
            "postal_code": "275292665",
            "telephone_number": "919-258-2714"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1745 CAMELOT DR",
            "address_2": "SUITE 100",
            "city": "VIRGINIA BEACH",
            "state": "VA",
            "postal_code": "234542435",
            "telephone_number": "757-961-4800",
            "fax_number": "757-961-0233"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TIDEWATER PHYSICAL THERAPY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-01-21",
        "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": "",
            "desc": "Physical Therapist",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "225X00000X",
            "taxonomy_group": "",
            "desc": "Occupational Therapist",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE GROUP PTAN",
            "identifier": "C05954",
            "state": "VA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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.