Healthcare Provider Details

I. General information

NPI: 1700984788
Provider Name (Legal Business Name): TIDALHEALTH PENINSULA REGIONAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 11/16/2020
Certification Date: 11/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E CARROLL ST FINANCE DEPT.
SALISBURY MD
21801-5422
US

IV. Provider business mailing address

100 E CARROLL ST FINANCE DEPT.
SALISBURY MD
21801-5422
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number21D0221168
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number22003
License Number StateMD

VIII. Authorized Official

Name: MICKEY GRIFFIN
Title or Position: SENIOR DIRECTOR PFS
Credential: CRCE
Phone: 410-543-7437