Healthcare Provider Details

I. General information

NPI: 1972188696
Provider Name (Legal Business Name): TIDEWATER PHYSICAL THERAPY ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2021
Last Update Date: 03/15/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6009 AMBERLY DR
BRADENTON FL
34208-4545
US

IV. Provider business mailing address

6009 AMBERLY DR
BRADENTON FL
34208-4545
US

V. Phone/Fax

Practice location:
  • Phone: 215-962-9557
  • Fax:
Mailing address:
  • Phone: 215-962-9557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. FRANK FEDORCZYK
Title or Position: OWNER
Credential: PT,DPT
Phone: 215-962-9557