Healthcare Provider Details

I. General information

NPI: 1285524256
Provider Name (Legal Business Name): TIDALHEALTH PRIMARY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2025
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 E CHURCH ST
SALISBURY MD
21804-4349
US

IV. Provider business mailing address

PO BOX 825474
PHILADELPHIA PA
19182-5474
US

V. Phone/Fax

Practice location:
  • Phone: 410-543-7717
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM PELOT
Title or Position: CHIEF ADMINISTRATOR OFFICER
Credential:
Phone: 410-543-7497