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NPI Code Detail

MEDICARE: TIDALHEALTH PHYSICIAN NETWORK, INC.

MEDICARE: TIDALHEALTH PHYSICIAN NETWORK, INC.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine Physician

General Provider Information

NPI Number : 1205649514
Entity Type Code : Organization
Provider Name (Legal Business Name) : TIDALHEALTH PHYSICIAN NETWORK, INC.
Provider Business Mailing Address
First Line : PO BOX 824327
Second Line :
City : PHILADELPHIA
State : PA
Zip : 19182-4327
Country : US
Telephone Number : 410-912-6989
Fax Number :
Provider Business Practice Location Address
First Line : 30549 SUSSEX HWY
Second Line :
City : LAUREL
State : DE
Zip : 19956-3891
Country : US
Telephone Number : 302-297-2579
Fax Number :
Authorized Official
Title or Position : CHIEF ADMINISTRATOR OFFICER
Name : WILLIAM PELOT
Credential :
Telephone Number : 410-543-7497
Provider Enumeration Date : 01/30/2025
Last Update Date : 07/22/2025

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