Provider Demographics
NPI:1174724991
Name:TIDALHEALTH PENINSULA REGIONAL, INC.
Entity type:Organization
Organization Name:TIDALHEALTH PENINSULA REGIONAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GARY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-912-6059
Mailing Address - Street 1:PO BOX 826880
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-5454
Mailing Address - Country:US
Mailing Address - Phone:410-546-6400
Mailing Address - Fax:410-912-4959
Practice Address - Street 1:145 E CARROLL ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-5454
Practice Address - Country:US
Practice Address - Phone:410-546-6400
Practice Address - Fax:410-912-4959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QI0500X
NY03000373282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282N00000XHospitalsGeneral Acute Care Hospital
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004236346Medicaid