1932648649 NPI number — TIDEWATER PHYSICAL THERAPY, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932648649 NPI number — TIDEWATER PHYSICAL THERAPY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIDEWATER PHYSICAL THERAPY, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PANTOPS PHYSICAL THERAPY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1932648649
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
350 NEW FIDELITY CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARNER
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27529-2665
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-258-2714
Provider Business Mailing Address Fax Number:
410-648-4878

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1490 PANTOPS MOUNTAIN PL
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
CHARLOTTESVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22911-4601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-245-6472
Provider Business Practice Location Address Fax Number:
434-245-6474
Provider Enumeration Date:
02/14/2017

Additional Information

Authorized Official

Authorized Official Last Name:
PEARSON
Authorized Official First Name:
PENNY
Authorized Official Middle Name:
Authorized Official Title or Position:
RCM DIRECTOR
Authorized Official Telephone Number:
443-225-4492

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: C05954 . This is a "GROUP MEDICARE PTAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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