NPIMap

Organization Active NPI

Tidewater Physical Therapy, LLC

  • Physical Therapist
  • Norfolk, VA
National Provider Identifier
1366477564
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
6161 Kempsville Cir
Suite 250
Norfolk, VA 23502-3932
Phone
(757) 965-4890
Fax
(757) 965-4893
NPI assigned
Jul 12, 2006
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 2

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

Addresses

Primary practice location

6161 Kempsville Cir
Suite 250
Norfolk, VA 23502-3932

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
192967OtherVABCBS (PT)

Medicare participation

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

Enrollment records 1

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

Other NPIs on the same Medicare enrollment 11

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

National Provider Directory

National Provider Directory

Locations

5629 Plank Rd
Ste 107
Fredericksburg, VA 22407
Phone (540) 445-0206

12494 Warwick Blvd
Newport News, VA 23606
Phone (804) 217-9210

4125 Ironbound Rd
Ste 100
Williamsburg, VA 23188
Phone (757) 220-8383

Practitioners & affiliated clinicians

Practitioners 15

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 15

NPI Registry JSON

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

{
    "created_epoch": "1152662400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1732492800000",
    "number": "1366477564",
    "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": "410-648-4878"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6161 KEMPSVILLE CIR",
            "address_2": "SUITE 250",
            "city": "NORFOLK",
            "state": "VA",
            "postal_code": "235023932",
            "telephone_number": "757-965-4890",
            "fax_number": "757-965-4893"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TIDEWATER PHYSICAL THERAPY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-12",
        "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": null,
            "license": null,
            "primary": true
        },
        {
            "code": "225X00000X",
            "taxonomy_group": "",
            "desc": "Occupational Therapist",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS (PT)",
            "identifier": "192967",
            "state": "VA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Norfolk, 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.