Healthcare Provider Details

I. General information

NPI: 1174347330
Provider Name (Legal Business Name): TIDALHEALTH SPECIALTY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2024
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1664 WOODBROOKE DR
SALISBURY MD
21804
US

IV. Provider business mailing address

PO BOX 825461 N/A
PHILADELPHIA PA
19182-0001
US

V. Phone/Fax

Practice location:
  • Phone: 410-912-6716
  • Fax:
Mailing address:
  • Phone: 410-912-6053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

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