NPIMap

Organization Active NPI

Tidewater Physical Therapy, LLC

  • Physical Therapist
  • Newport News, VA
National Provider Identifier
1669493474
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
Practice address
751 J Clyde Morris Blvd
Newport News, VA 23601-1538
Phone
(757) 873-2123
Fax
(757) 873-3848
NPI assigned
Jul 21, 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
Title
Credentialing Manager
Phone
(252) 248-3313

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X NU
Physical Therapist 225100000X NU Primary
Occupational Therapist 225X00000X NU

Addresses

Primary practice location

751 J Clyde Morris Blvd
Newport News, VA 23601-1538

Mailing address

2122 York Rd Ste 300
Oak Brook, IL 60523-1925
Phone (630) 575-1980

Other identifiers 1

IdentifierTypeStateIssuer
192931OtherVABCBS (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

Practitioners & affiliated clinicians

Practitioners 11

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.

NPI Registry JSON

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

{
    "created_epoch": "1153440000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1731974400000",
    "number": "1669493474",
    "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": "630-575-1980",
            "fax_number": "630-928-5080"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "751 J CLYDE MORRIS BLVD",
            "city": "NEWPORT NEWS",
            "state": "VA",
            "postal_code": "236011538",
            "telephone_number": "757-873-2123",
            "fax_number": "757-873-3848"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TIDEWATER PHYSICAL THERAPY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-21",
        "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": "CREDENTIALING MANAGER",
        "authorized_official_telephone_number": "252-248-3313"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "225X00000X",
            "taxonomy_group": "",
            "desc": "Occupational Therapist",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS (PT)",
            "identifier": "192931",
            "state": "VA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Newport News, 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.