NPIMap

Organization Active NPI

Tidewater Physical Therapy, LLC

Doing business as Pivot Physical Therapy of Virginia

  • Physical Therapist
  • Glen Allen, VA
National Provider Identifier
1457389595
Registry record updated Nov 19, 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
10128 W Broad St BLDG III
Glen Allen, VA 23060-6761
Phone
(804) 217-9210
Fax
(804) 217-9213
NPI assigned
Jun 29, 2006
Last updated
Nov 19, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 19, 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 4

Specialty (taxonomy)CodeLicenseStatePrimary
Physical TherapistGroup: 193200000X MULTI-SPECIALTY GROUP 225100000X Primary
Occupational TherapistGroup: 193200000X MULTI-SPECIALTY GROUP 225X00000X
Speech-Language PathologistGroup: 193200000X MULTI-SPECIALTY GROUP 235Z00000X
Clinic/Center 261Q00000X

Addresses

Primary practice location

10128 W Broad St BLDG III
Glen Allen, VA 23060-6761

Mailing address

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

Other names 1

  • Pivot Physical Therapy of Virginia Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in VA, DC2 enrollments

Enrollment records 2

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
O20260514002582 DC Part B Supplier - Physical/Occupational Therapy Group in Private Practice 6406759281 Receives reassigned benefits from 23 practitioners
Practice locations: Fairfax, VA; Springfield, VA; Herndon, VA; Falls Church, VA; Arlington, VA; Alexandria, VA

Other NPIs with the same Medicare PAC ID 4

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

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
Tax ID family
Tidewater Physical Therapy Inc28 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 (25 of 29)

2400 Lakeside Dr
Ste 602F
Baltimore, MD 21264

350 New Fidelity Ct
Ste 311
Garner, NC 27529

4020 Raintree Rd
Ste D
Chesapeake, VA 23321
Phone (757) 366-0692

10438 Iron Bridge Rd
Chester, VA 23831
Phone (804) 248-8277

10438 Iron Bridge Rd
Unit 34
Chester, VA 23831
Phone (757) 873-2302

1580 Armory Dr
Ste 100
Franklin, VA 23851

10128 W Broad St
Ste 3K
Glen Allen, VA 23060

6965 Fox Hunt Ln
Ste 201
Gloucester, VA 23061
Phone (804) 694-8111

9 Manhattan Sq
Ste B
Hampton, VA 23666
Phone (757) 284-3997

3051 George Washington Memorial Hwy
#8
Hayes, VA 23072

7190 Chapman Dr
Hayes, VA 23072
Phone (800) 464-2302

7493 Right Flank Rd
Mechanicsville, VA 23116

7493 Right Flank Rd
Ste 410
Mechanicsville, VA 23116
Phone (804) 569-7091

12725 McManus Blvd
Ste 2E
Newport News, VA 23602
Phone (757) 874-0032

751 J Clyde Morris Blvd
Newport News, VA 23601
Phone (757) 596-1900

751 Thimble Shoals Blvd
Newport News, VA 23606

823 Poplar Hall Dr
Norfolk, VA 23502

3510 Anderson Hwy
Ste 2
Powhatan, VA 23139
Phone (804) 598-2100

3100 W Marshall St
Richmond, VA 23230
Phone (804) 342-5857

4831 S Laburnum Ave
Richmond, VA 23231
Phone (804) 222-0745

2033 Colonial Ave SW
Ste 138
Roanoke, VA 24015
Phone (540) 466-3981

204 Gumwood Dr
Smithfield, VA 23430
Phone (757) 357-7762

7223 Commerce St
Ste 40
Springfield, VA 22150
Phone (703) 935-1999

392 Garrisonville Rd
Ste 208
Stafford, VA 22554
Phone (540) 602-4277

2007 Meade Pkwy
Suffolk, VA 23434
Phone (757) 539-6300

Practitioners & affiliated clinicians

Practitioners 448

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 448

NPI Registry JSON

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

{
    "created_epoch": "1151539200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1731974400000",
    "number": "1457389595",
    "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": "10128 W BROAD ST BLDG III",
            "city": "GLEN ALLEN",
            "state": "VA",
            "postal_code": "230606761",
            "telephone_number": "804-217-9210",
            "fax_number": "804-217-9213"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TIDEWATER PHYSICAL THERAPY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-29",
        "last_updated": "2024-11-19",
        "certification_date": "2024-11-19",
        "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
        },
        {
            "code": "225X00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Occupational Therapist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "235Z00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Speech-Language Pathologist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Pivot Physical Therapy of Virginia",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Glen Allen, VA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 19, 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.