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General NPI Number Information
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NPI Number | 1427298629
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Entity Type | Organization
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Legal Business Name | TIDALHEALTH PENINSULA REGIONAL, INC.
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Dates
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Enumeration Date | 02/27/2009
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Last Update Date | 11/16/2020
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Provider Practice Location Address
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Address Line | 100 E CARROLL ST
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City | SALISBURY
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State | MD
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Zip | 21801-5422
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Country | US
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Telephone | 410-543-7437
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Fax | 410-543-7020
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Provider Business Mailing Address
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Address Line | PO BOX 2498
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City | SALISBURY
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State | MD
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Zip | 21802-2498
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Country | US
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Telephone | 410-543-7437
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Fax | 410-543-7020
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Authorized Official
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Title or Position | DIRECTOR, PFS
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Name | MRS. MICKEY M GRIFFIN
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Credential | CRCE
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Telephone | 410-543-7437
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 22-003
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License Number State | MD
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