Healthcare Provider Details

I. General information

NPI: 1336968619
Provider Name (Legal Business Name): TIDALHEALTH PENINSULA REGIONAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2024
Last Update Date: 10/04/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E CARROLL ST
SALISBURY MD
21801-5422
US

IV. Provider business mailing address

PO BOX 826880
PHILADELPHIA PA
19182-6880
US

V. Phone/Fax

Practice location:
  • Phone: 410-543-4716
  • Fax:
Mailing address:
  • Phone: 410-543-7324
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE GARY
Title or Position: VICE PRESIDENT FINANCE
Credential:
Phone: 410-546-6400