Basic Information
| Provider Information | |||||||||
| NPI: | 1881133791 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TIDEWATER PHYSICAL THERAPY, LLC | ||||||||
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| OtherOrganizationName: | PANTOPS PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 NEW FIDELITY CT | ||||||||
| Address2: | |||||||||
| City: | GARNER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275292665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192582714 | ||||||||
| FaxNumber: | 4106484878 | ||||||||
| Practice Location | |||||||||
| Address1: | 77 MARKET ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | PALMYRA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229634687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4345107301 | ||||||||
| FaxNumber: | 4345107418 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2017 | ||||||||
| LastUpdateDate: | 05/05/2020 | ||||||||
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| AuthorizedOfficialLastName: | PEARSON | ||||||||
| AuthorizedOfficialFirstName: | PENNY | ||||||||
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| AuthorizedOfficialTitleorPosition: | RCM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4432254492 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | VA | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | C05954 | 01 | VA | MEDICARE GROUP PTAN | OTHER |