Healthcare Provider Details

I. General information

NPI: 1982171005
Provider Name (Legal Business Name): TIDALHEALTH PENINSULA REGIONAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2018
Last Update Date: 10/26/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 MILFORD ST STE 404
SALISBURY MD
21804-6967
US

IV. Provider business mailing address

100 E CARROLL ST
SALISBURY MD
21801-5422
US

V. Phone/Fax

Practice location:
  • Phone: 410-543-7294
  • Fax:
Mailing address:
  • Phone: 410-543-7437
  • Fax: 410-543-7020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number State

VIII. Authorized Official

Name: MRS. MICKEY GRIFFIN
Title or Position: DIRECTOR OF PATIENT FINANCIAL SERV
Credential:
Phone: 410-543-7437