Healthcare Provider Details

I. General information

NPI: 1932423753
Provider Name (Legal Business Name): ATLANTIC GENERAL HOSPITAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2010
Last Update Date: 05/30/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9733 HEALTHWAY DR
BERLIN MD
21811-1155
US

IV. Provider business mailing address

9733 HEALTHWAY DR
BERLIN MD
21811-1155
US

V. Phone/Fax

Practice location:
  • Phone: 410-641-1100
  • Fax: 410-641-9219
Mailing address:
  • Phone: 410-641-1100
  • Fax: 410-641-9219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number21D0869030
License Number StateMD

VIII. Authorized Official

Name: STEPHANIE GARY
Title or Position: SVP, FINANCE/CFO OF TIDALHEALTH
Credential:
Phone: 410-912-6059