Healthcare Provider Details

I. General information

NPI: 1952263014
Provider Name (Legal Business Name): TIDALHEALTH PRIMARY 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

10614 RACETRACK RD UNIT 1
BERLIN MD
21811-3383
US

IV. Provider business mailing address

PO BOX 825474
PHILADELPHIA PA
19182-5474
US

V. Phone/Fax

Practice location:
  • Phone: 443-728-1004
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

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