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Tidewater Physical Therapy, LLC

Organization Active NPI Physical Therapist · Glen Allen, VA

NPI 1477588986 · NPPES record last updated Nov 25, 2024

Key facts

NPI
1477588986
Entity type
Organization (NPI type 2)
Primary specialty
Physical Therapist 225100000X
Legal business name
TIDEWATER PHYSICAL THERAPY, LLC
Practice address
10128 W Broad St
Forum Building III, Suite K
Glen Allen, VA 23060-6761
Phone
(804) 217-9210
Fax
(804) 217-9213
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

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

Other NPIs with the same Medicare PAC ID 4

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

Corporate family (same tax ID) 27

Organizations that report the same tax identification number in the National Provider Directory.

View all 27

Practitioners 237

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 237

Medicare participation

Medicare fee-for-service enrollment
Enrolled (2 enrollments) in VA

Medicare enrollment records

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
O20100930072014 VA DME Supplier - Independently-Practicing Physical Therapist 6406759281 Practice locations: Glen Allen, VA

National Provider Directory

Tax ID family
Tidewater Physical Therapy LLC (28 organizations share this tax ID)

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Physical Therapist
Group: 193200000X MULTI-SPECIALTY GROUP		 225100000X Yes
Occupational Therapist
Group: 193200000X MULTI-SPECIALTY GROUP		 225X00000X

Addresses

Primary practice location

10128 W Broad St
Forum Building III, Suite K
Glen Allen, VA 23060-6761

Mailing address

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

Other identifiers

IdentifierTypeStateIssuer
192953OtherVABCBS (PT)

Other providers in Glen Allen, VA

All providers in Glen Allen, VA · Physical Therapist in Virginia

Sources for this page

Verify at the official NPI Registry.