Provider Demographics
NPI:1114784188
Name:TIDALHEALTH PRIMARY CARE, LLC
Entity Type:Organization
Organization Name:TIDALHEALTH PRIMARY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT - FINANCE
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:410-912-4976
Mailing Address - Street 1:560 RIVERSIDE DR STE B204
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-4703
Mailing Address - Country:US
Mailing Address - Phone:410-543-7720
Mailing Address - Fax:
Practice Address - Street 1:560 RIVERSIDE DR STE B204
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-4703
Practice Address - Country:US
Practice Address - Phone:410-543-7720
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-05
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty