Healthcare Provider Details

I. General information

NPI: 1902549728
Provider Name (Legal Business Name): TIDA HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2022
Last Update Date: 06/02/2022
Certification Date: 06/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2209 MONTAUK DR
CROFTON MD
21114-3245
US

IV. Provider business mailing address

2209 MONTAUK DR
CROFTON MD
21114-3245
US

V. Phone/Fax

Practice location:
  • Phone: 443-570-7610
  • Fax:
Mailing address:
  • Phone: 443-570-7610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: IDA KONCHOU
Title or Position: CEO
Credential: CRNP
Phone: 443-570-7610