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? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207P00000X | Allopathic & Osteopathic Physicians | Emergency Medicine | Group - Multi-Specialty | |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Multi-Specialty |
No | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Multi-Specialty |
No | 207RH0003X | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | Group - Multi-Specialty |
No | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Multi-Specialty |
No | 207T00000X | Allopathic & Osteopathic Physicians | Neurological Surgery | Group - Multi-Specialty | |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 208D00000X | Allopathic & Osteopathic Physicians | General Practice | Group - Multi-Specialty | |
No | 208G00000X | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | Group - Multi-Specialty | |
No | 261QM0850X | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | Group - Multi-Specialty |
No | 261QM0855X | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | Group - Multi-Specialty |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MD | CC4271 | Other | MEDICARE RRB |
MD | CA8333 | Other | MEDICARE RRB |
DE | 0000241502 | Medicaid | |
VA | C10607 | Other | MEDICARE PTAN |
MD | K230 | Other | MEDICARE NSC |
MD | K230 | Other | MEDICARE PTAN |
MD | 401428600 | Medicaid | |
DE | CA8334 | Other | MEDICARE RRB |
DE | G01753 | Other | MEDICARE NSC |
MD | 525701800 | Medicaid | |
VA | C10607 | Other | MEDICARE NSC |
MD | CC3716 | Other | MEDICARE RRB |
DE | G01753 | Other | MEDICARE PTAN |