Tidewater Physical Therapy, LLC
Organization Active NPI Physical Therapist · Norfolk, VA
NPI 1366477564 · NPPES record last updated Nov 25, 2024
Key facts
- NPI
- 1366477564
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Physical Therapist 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
- Organization subpart
- No
Authorized official
- Name
- Tasheda Broughton, PESC
- Title
- Manager, Credentialing
- Phone
- (252) 248-3313
Other NPIs on the same Medicare enrollment 11
Practitioners 15
-
Brittany Renee Deuso, PT, DPT
-
Monica Guerra, PT, DPT
-
Rafal M Gwizdala, DPT
-
Sue B. Hunter, MS, ED., CCC-SLP
-
William C Lambert, PT, DPT
-
Emily E Leister, PT, DPT
-
Lindsey Ann Lyon, PT, DPT
-
Maureen McGrath, PT, DPT
-
Molly A. Myers, PT, DPT
-
Melissa A Ryman, PT, DPT, ATC
-
Ryan Christopher Thompson, PT, DPT
-
Daniel A Griffin, PT, DPT
-
Daniel J Kellar, PT, DPT
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in VA
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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
Locations
12494 Warwick Blvd
Newport News, VA 23606
Phone (804) 217-9210
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapist |
225100000X | Yes | ||
| 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
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 192967 | Other | VA | BCBS (PT) |
Other providers in Norfolk, VA
- Tidewater Hyperbaric
- Tidewater Kidney Specialists, Inc.
- Tidewater Pastoral Counseling Services, Inc
- Tidewater Physical Therapy LLC
- Tidewater Physical Therapy LLC
- Tidewater Podiatry Group LTD
- Tidewater Speech and Language Services
- Tidewater Superior Home Support LLC
- Tidewater Vision Occupational Therapy PLLC
- Tidewater Weight Loss and Wellness Centers,Inc.
All providers in Norfolk, VA · Physical Therapist in Virginia
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 25, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.