Healthcare Provider Details

I. General information

NPI: 1821817198
Provider Name (Legal Business Name): TIDALHEALTH PRIMARY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2024
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 W MARKET ST
SNOW HILL MD
21863-1127
US

IV. Provider business mailing address

PO BOX 825474
PHILADELPHIA PA
19182-5474
US

V. Phone/Fax

Practice location:
  • Phone: 410-912-4950
  • Fax:
Mailing address:
  • Phone: 410-912-6989
  • Fax: 410-912-4972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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