Provider Demographics
NPI:1366477879
Name:TIDEWATER PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:TIDEWATER PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RCM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:PEARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-225-4492
Mailing Address - Street 1:350 NEW FIDELITY CT
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-2665
Mailing Address - Country:US
Mailing Address - Phone:919-258-2714
Mailing Address - Fax:410-648-4878
Practice Address - Street 1:7190 CHAPMAN DR
Practice Address - Street 2:
Practice Address - City:HAYES
Practice Address - State:VA
Practice Address - Zip Code:23072-3416
Practice Address - Country:US
Practice Address - Phone:804-642-3028
Practice Address - Fax:804-642-3467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA192964OtherBCBS (OT)
VA192962OtherBCBS (PT)
VA=========030OtherTRICARE
VA192962OtherBCBS (PT)
0831850016Medicare NSC