Healthcare Provider Details

I. General information

NPI: 1063374114
Provider Name (Legal Business Name): TIDALHEALTH SPECIALTY CARE, LLC
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

10231 OLD OCEAN CITY BLVD STE 104
BERLIN MD
21811-3567
US

IV. Provider business mailing address

PO BOX 825461
PHILADELPHIA PA
19182-5461
US

V. Phone/Fax

Practice location:
  • Phone: 410-629-6863
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: SLOAN TRAMMELL
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 410-912-6989