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	342325	OTHER	VA	BCBS OCCUPATIONAL THERAPY
2	342327	OTHER	VA	BCBS PHYSICAL THERAPY

General Provider Information

NPI Number	:	1982889408
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	:	252-248-3133
Fax Number	:	410-648-4878

Provider Business Practice Location Address
First Line	:	7493 RIGHT FLANK RD
Second Line	:	SUITE 410
City	:	MECHANICSVILLE
State	:	VA
Zip	:	23116-3846
Country	:	US
Telephone Number	:	804-569-7091
Fax Number	:	804-569-7094

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

Provider Enumeration Date	:	01/03/2008
Last Update Date	:	12/06/2024

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