=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790598985
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TIDALHEALTH SPECIALTY CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2025
-----------------------------------------------------
Last Update Date | 07/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 804 SNOW HILL RD
-----------------------------------------------------
City | SALISBURY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21804-1938
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-543-6400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 825461
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19182-5461
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-912-6053
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF ADMINISTRATIVE OFFICER
-----------------------------------------------------
Name | WILLIAM PELOT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 410-543-7497
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------