Healthcare Provider Details

I. General information

NPI: 1306507579
Provider Name (Legal Business Name): TIDALHEALTH PENINSULA REGIONAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2022
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 HALL HWY
CRISFIELD MD
21817-1237
US

IV. Provider business mailing address

PO BOX 826880
PHILADELPHIA PA
19182-6880
US

V. Phone/Fax

Practice location:
  • Phone: 410-968-1200
  • Fax:
Mailing address:
  • Phone: 410-912-6989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRUCE ISHMAEL RITCHIE
Title or Position: SR. VICE PRESIDENT/CFO
Credential:
Phone: 410-543-7298