Healthcare Provider Details

I. General information

NPI: 1033592662
Provider Name (Legal Business Name): TIDALHEALTH PENINSULA REGIONAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2015
Last Update Date: 10/26/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 SNOW HILL RD
SALISBURY MD
21804-1938
US

IV. Provider business mailing address

100 E CARROLL ST
SALISBURY MD
21801-5422
US

V. Phone/Fax

Practice location:
  • Phone: 410-543-7599
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRUCE RITCHIE
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 410-543-7298