MEDICARE: TIDEWATER PHYSICAL THERAPY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist
2	225100000X	Physical Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	192953	OTHER	VA	BCBS (PT)

General Provider Information

NPI Number	:	1477588986
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIDEWATER PHYSICAL THERAPY, LLC

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

Provider Business Practice Location Address
First Line	:	10128 W BROAD ST
Second Line	:	FORUM BUILDING III, SUITE K
City	:	GLEN ALLEN
State	:	VA
Zip	:	23060-6761
Country	:	US
Telephone Number	:	804-217-9210
Fax Number	:	804-217-9213

Authorized Official
Title or Position	:	MANAGER, CREDENTIALING
Name	:	TASHEDA BROUGHTON
Credential	:	PESC
Telephone Number	:	252-248-3313

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	11/25/2024

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