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	192941	OTHER	VA	BCBS (PT)

General Provider Information

NPI Number	:	1215952361
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIDEWATER PHYSICAL THERAPY, LLC

Provider Business Mailing Address
First Line	:	350 NEW FIDELITY CT
Second Line	:
City	:	GARNER
State	:	NC
Zip	:	27529-2665
Country	:	US
Telephone Number	:	919-258-2714
Fax Number	:

Provider Business Practice Location Address
First Line	:	4020 RAINTREE RD
Second Line	:	STE D
City	:	CHESAPEAKE
State	:	VA
Zip	:	23321-3749
Country	:	US
Telephone Number	:	757-484-4241
Fax Number	:	757-484-4487

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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