1609004571 NPI number — TIDEWATER PHYSICAL THERAPY, LLC

Table of content: (NPI 1609004571)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609004571 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:
Provider Other Organization Name Type Code:
6
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:
1609004571
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2122 YORK RD STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK BROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60523-1925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-248-3313
Provider Business Mailing Address Fax Number:
410-648-4878

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3510 ANDERSON HWY
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
POWHATAN
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-598-2100
Provider Business Practice Location Address Fax Number:
804-598-7624
Provider Enumeration Date:
06/30/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BROUGHTON
Authorized Official First Name:
TASHEDA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER, CREDENTIALING
Authorized Official Telephone Number:
252-248-3313

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: 223951124 . This is a "DEPT OF LABOR/ACS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1609004571 . This is a "BCBS (PHYSICAL THERAPY)" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1609004571 . This is a "BCBS (OCCUPATIONAL THERAPY)" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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