=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003618026
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATLANTIC GENERAL HOSPITAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2025
-----------------------------------------------------
Last Update Date | 05/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6040 PUBLIC LANDING RD
-----------------------------------------------------
City | SNOW HILL
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21863-2453
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-629-0041
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9733 HEALTHWAY DR # 41
-----------------------------------------------------
City | BERLIN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21811-1155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-629-6037
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SVP, FINANCE/CFO OF TIDALHEALTH
-----------------------------------------------------
Name | STEPHANIE GARY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 410-912-6059
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------