Healthcare Provider Details

I. General information

NPI: 1538026505
Provider Name (Legal Business Name): TIDALHEALTH PENINSULA REGIONAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2026
Last Update Date: 01/09/2026
Certification Date: 01/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11105 CATHAGE RD
BERLIN MD
21811-2131
US

IV. Provider business mailing address

11105 CATHAGE RD
BERLIN MD
21811-2131
US

V. Phone/Fax

Practice location:
  • Phone: 410-912-4934
  • Fax:
Mailing address:
  • Phone: 410-912-4934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State

VIII. Authorized Official

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