=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184442725
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATLANTIC GENERAL HOSPITAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2024
-----------------------------------------------------
Last Update Date | 05/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10231 OLD OCEAN CITY BLVD STE 207
-----------------------------------------------------
City | BERLIN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21811-3568
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-641-9568
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9733 HEALTHWAY DR
-----------------------------------------------------
City | BERLIN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21811-1156
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-641-1100
-----------------------------------------------------
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 | 207RB0002X
-----------------------------------------------------
Taxonomy Name | Obesity Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------