Healthcare Provider Details

I. General information

NPI: 1538972849
Provider Name (Legal Business Name): TIDALHEALTH PHYSICIAN NETWORK, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2025
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 MIDDLEFORD RD # A
SEAFORD DE
19973-3600
US

IV. Provider business mailing address

PO BOX 824327
PHILADELPHIA PA
19182-4327
US

V. Phone/Fax

Practice location:
  • Phone: 302-628-6344
  • Fax:
Mailing address:
  • Phone: 410-912-6989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM PELOT
Title or Position: CHIEF ADMINISTRATOR OFFICER
Credential:
Phone: 410-543-7497