NPIMap

Individual provider Active NPI

Calla L. Selfridge, PT, DPT, CMTPT

  • Physical Therapist
  • Smithfield, VA
National Provider Identifier
1730415944
Registry record updated May 3, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physical TherapistTaxonomy code 225100000X
License
2305206270 Issued in VA
Practice address
204 Gumwood Dr
Smithfield, VA 23430-6087
Phone
(757) 357-7762
Fax
(757) 357-7765
NPI assigned
Oct 22, 2009
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on May 3, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physical Therapist 225100000X 2305206270 VA Primary

Addresses

Primary practice location

204 Gumwood Dr
Smithfield, VA 23430-6087

Mailing address

PO Box 69030
Baltimore, MD 21264-9030
Phone (757) 873-2302

Other identifiers 4

IdentifierTypeStateIssuer
C05954OtherVAGROUP MEDICARE PTAN
P00771554OtherVARAILROAD MEDICARE
1730415944MedicaidVA
9304404OtherVAAETNA

Other names 1

  • Calla L. Deruosi Former name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled

State licenses

LicenseStateTypeSpecialty
2305206270VAMDPhysical Therapist

Practice roles

OrganizationSpecialtyStatusNew patients
Tidewater Physical Therapy LLC Physical Therapist Past Accepting new patients
Tidewater Physical Therapy LLC Physical Therapist Past Accepting new patients
Tidewater Physical Therapy, LLC Physical Therapist Past Accepting new patients
Tidewater Physical Therapy, LLC Physical Therapist Past Accepting new patients
Tidewater Physical Therapy LLC Physical Therapist Past Accepting new patients

Organizations & group practices 5

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1256169600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1525305600000",
    "number": "1730415944",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 69030",
            "city": "BALTIMORE",
            "state": "MD",
            "postal_code": "212649030",
            "telephone_number": "757-873-2302",
            "fax_number": "757-873-2306"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "204 GUMWOOD DR",
            "city": "SMITHFIELD",
            "state": "VA",
            "postal_code": "234306087",
            "telephone_number": "757-357-7762",
            "fax_number": "757-357-7765"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SELFRIDGE",
        "first_name": "CALLA",
        "middle_name": "L.",
        "credential": "PT, DPT, CMTPT",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2009-10-22",
        "last_updated": "2018-05-03",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "VA",
            "license": "2305206270",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GROUP MEDICARE PTAN",
            "identifier": "C05954",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "P00771554",
            "state": "VA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1730415944",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AETNA",
            "identifier": "9304404",
            "state": "VA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "CALLA",
            "last_name": "DERUOSI",
            "middle_name": "L.",
            "credential": "PT, DPT",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

Other providers in Smithfield, VA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 3, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.