Healthcare Provider Details

I. General information

NPI: 1740176098
Provider Name (Legal Business Name): TIDALHEALTH SPECIALTY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2025
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11105 CATHAGE RD
BERLIN MD
21811-2131
US

IV. Provider business mailing address

PO BOX 825461
PHILADELPHIA PA
19182-5461
US

V. Phone/Fax

Practice location:
  • Phone: 410-912-4934
  • Fax:
Mailing address:
  • Phone: 410-912-6053
  • 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 ADMINISTRATIVE OFFICER
Credential:
Phone: 410-543-7497