Provider Demographics
NPI:1184832040
Name:TIDALHEALTH PENINSULA REGIONAL, INC.
Entity Type:Organization
Organization Name:TIDALHEALTH PENINSULA REGIONAL, INC.
Other - Org Name:
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 1:100 E CARROLL ST
Mailing Address - Street 2:PENINSULA REGIONAL MEDICAL GROUP
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-5422
Mailing Address - Country:US
Mailing Address - Phone:410-543-7252
Mailing Address - Fax:410-912-6386
Practice Address - Street 1:100 E CARROLL ST
Practice Address - Street 2:PENINSULA REGIONAL MEDICAL GROUP
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-5422
Practice Address - Country:US
Practice Address - Phone:410-543-7252
Practice Address - Fax:410-912-6386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDCC4271OtherMEDICARE RRB
MDCA8333OtherMEDICARE RRB
DE0000241502Medicaid
VAC10607OtherMEDICARE PTAN
MDK230OtherMEDICARE NSC
MDK230OtherMEDICARE PTAN
MD401428600Medicaid
DECA8334OtherMEDICARE RRB
DEG01753OtherMEDICARE NSC
MD525701800Medicaid
VAC10607OtherMEDICARE NSC
MDCC3716OtherMEDICARE RRB
DEG01753OtherMEDICARE PTAN