Provider Demographics
NPI:1457389595
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 STE 311
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 1:771 PILOT HOUSE DR
Practice Address - Street 2:SUITE A
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-1990
Practice Address - Country:US
Practice Address - Phone:757-873-2302
Practice Address - Fax:757-873-2306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
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
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC12068OtherMEDICARE RAILROAD
VAC08381Medicare PIN
VAC06705Medicare PIN
VAC06586Medicare PIN
VAC07071Medicare PIN
NC2337317Medicare PIN
VAC12068OtherMEDICARE RAILROAD
VAC05954Medicare PIN