Provider Demographics
NPI:1427561984
Name:TIDEWATER PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:TIDEWATER PHYSICAL THERAPY LLC
Other - Org Name:PIVOT PHYSICAL THERAPY OF VIRGINIA
Other - Org Type:Doing Business As
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 1:10518 SPOTSYLVANIA AVE STE 100
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22408-2693
Practice Address - Country:US
Practice Address - Phone:540-710-5341
Practice Address - Fax:540-710-5372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-07
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
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05954OtherGROUP MEDICARE PTAN