Provider Demographics
NPI:1972188696
Name:TIDEWATER PHYSICAL THERAPY ASSOCIATES LLC
Entity Type:Organization
Organization Name:TIDEWATER PHYSICAL THERAPY ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:FEDORCZYK
Authorized Official - Suffix:
Authorized Official - Credentials:PT,DPT
Authorized Official - Phone:215-962-9557
Mailing Address - Street 1:6009 AMBERLY DR
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-4545
Mailing Address - Country:US
Mailing Address - Phone:215-962-9557
Mailing Address - Fax:
Practice Address - Street 1:6009 AMBERLY DR
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-4545
Practice Address - Country:US
Practice Address - Phone:215-962-9557
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-15
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty