MEDICARE: TIDALHEALTH PENINSULA REGIONAL, INC.

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	291U00000X	Clinical Medical Laboratory	22003	MD
2	282N00000X	General Acute Care Hospital	22003	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780689463
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIDALHEALTH PENINSULA REGIONAL, INC.

Provider Business Mailing Address
First Line	:	100 E CARROLL ST
Second Line	:
City	:	SALISBURY
State	:	MD
Zip	:	21801-5422
Country	:	US
Telephone Number	:	410-546-6400
Fax Number	:	410-543-7020

Provider Business Practice Location Address
First Line	:	100 E CARROLL ST
Second Line	:
City	:	SALISBURY
State	:	MD
Zip	:	21801-5422
Country	:	US
Telephone Number	:	410-546-6400
Fax Number	:	410-543-7020

Authorized Official
Title or Position	:	PRESIDENT/C.E.O.
Name	:	STEVEN LEONARD
Credential	:
Telephone Number	:	410-546-6400

Provider Enumeration Date	:	06/17/2005
Last Update Date	:	10/23/2020

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