Active NPI
Tidewater Physical Therapy, LLC
- Physical Therapist
- Midlothian, VA
National Provider Identifier
1508896622
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapist
- Legal business name
- TIDEWATER PHYSICAL THERAPY, LLC
- Practice address
- 6049 Harbour Park Dr
Midlothian, VA 23112-2160 - Phone
- (804) 639-2359
- Fax
- (804) 639-2029
- NPI assigned
- Jul 4, 2006
- Organization subpart
- No
NPPES NPI Registry
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) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapist | 225100000X | Primary | ||
| Occupational Therapist | 225X00000X |
Addresses
Primary practice location
6049 Harbour Park Dr
Midlothian, VA 23112-2160
Mailing address
2122 York Rd Ste 300
Oak Brook, IL 60523-1925
Phone (919) 258-2714
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| OT - 192945 | Other | VA | BLUE CROSS BLUE SHIELD |
| PT - 192944 | Other | VA | BLUE CROSS BLUE SHIELD |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in VA
Enrollment records 1
| 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
National Provider DirectoryOther NPIs on the same Medicare enrollment 11
NPIs listed together on one Medicare enrollment, typically parts of the same organization.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1151971200000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1732492800000",
"number": "1508896622",
"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": "919-258-2714",
"fax_number": "410-648-4878"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "6049 HARBOUR PARK DR",
"city": "MIDLOTHIAN",
"state": "VA",
"postal_code": "231122160",
"telephone_number": "804-639-2359",
"fax_number": "804-639-2029"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "TIDEWATER PHYSICAL THERAPY, LLC",
"organizational_subpart": "NO",
"enumeration_date": "2006-07-04",
"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
},
{
"code": "225X00000X",
"taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
"desc": "Occupational Therapist",
"state": null,
"license": null,
"primary": false
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE CROSS BLUE SHIELD",
"identifier": "OT - 192945",
"state": "VA"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE CROSS BLUE SHIELD",
"identifier": "PT - 192944",
"state": "VA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Midlothian, 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.