NPIMap

Organization Active NPI

Tidewater Physical Therapy LLC

  • Physical Therapist
  • Suffolk, VA
National Provider Identifier
1144972159
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
1033 Champions Way Ste 500
Suffolk, VA 23435-3775
Phone
(757) 372-9953
Fax
(757) 372-9954
NPI assigned
Jan 20, 2022
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 TherapistGroup: 193200000X MULTI-SPECIALTY GROUP 225100000X Primary

Addresses

Primary practice location

1033 Champions Way Ste 500
Suffolk, VA 23435-3775

Mailing address

350 New Fidelity CT
Garner, NC 27529-2665
Phone (919) 578-4538

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

Locations

1033 Champions Way
Ste 500
Suffolk, VA 23435
Phone (757) 372-9953

NPI Registry JSON

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

{
    "created_epoch": "1642636800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1732492800000",
    "number": "1144972159",
    "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": "919-578-4538"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1033 CHAMPIONS WAY STE 500",
            "city": "SUFFOLK",
            "state": "VA",
            "postal_code": "234353775",
            "telephone_number": "757-372-9953",
            "fax_number": "757-372-9954"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TIDEWATER PHYSICAL THERAPY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-01-20",
        "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": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physical Therapist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Suffolk, 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.