Basic Information
| Provider Information | |||||||||
| NPI: | 1982889408 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TIDEWATER PHYSICAL THERAPY, LLC | ||||||||
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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: | 7493 RIGHT FLANK RD | ||||||||
| Address2: | SUITE 410 | ||||||||
| City: | MECHANICSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 231163846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045697091 | ||||||||
| FaxNumber: | 8045697094 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2008 | ||||||||
| 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 | 225X00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 342327 | 01 | VA | BCBS PHYSICAL THERAPY | OTHER | 342325 | 01 | VA | BCBS OCCUPATIONAL THERAPY | OTHER |