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General NPI Number Information
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NPI Number | 1952263014
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Entity Type | Organization
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Legal Business Name | TIDALHEALTH PRIMARY CARE, LLC
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Dates
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Enumeration Date | 11/26/2025
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Last Update Date | 11/26/2025
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Provider Practice Location Address
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Address Line | 10614 RACETRACK RD UNIT 1
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City | BERLIN
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State | MD
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Zip | 21811-3383
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Country | US
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Telephone | 443-728-1004
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 825474
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City | PHILADELPHIA
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State | PA
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Zip | 19182-5474
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING MANAGER
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Name | SLOAN TRAMMELL
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Credential |
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Telephone | 410-912-6989
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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