Healthcare Provider Details

I. General information

NPI: 1972465094
Provider Name (Legal Business Name): TIDALHEALTH PHYSICIAN NETWORK, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2025
Last Update Date: 11/26/2025
Certification Date: 11/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 MIDDLEFORD RD
SEAFORD DE
19973-3636
US

IV. Provider business mailing address

PO BOX 824327
PHILADELPHIA PA
19182-4327
US

V. Phone/Fax

Practice location:
  • Phone: 302-629-6611
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

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