Basic Information
Provider Information | |||||||||
NPI: | 1477588986 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TIDEWATER PHYSICAL THERAPY, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 350 NEW FIDELITY CT | ||||||||
Address2: |   | ||||||||
City: | GARNER | ||||||||
State: | NC | ||||||||
PostalCode: | 275292665 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9192582714 | ||||||||
FaxNumber: | 4106484878 | ||||||||
Practice Location | |||||||||
Address1: | 10128 W BROAD ST | ||||||||
Address2: | FORUM BUILDING III, SUITE K | ||||||||
City: | GLEN ALLEN | ||||||||
State: | VA | ||||||||
PostalCode: | 230606761 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8042179210 | ||||||||
FaxNumber: | 8042179213 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2006 | ||||||||
LastUpdateDate: | 05/05/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PEARSON | ||||||||
AuthorizedOfficialFirstName: | PENNY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | RCM DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 4432254492 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/05/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 225100000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 192953 | 01 | VA | BCBS (PT) | OTHER |