TIDALHEALTH PENINSULA REGIONAL, INC.

Provider Demographics

• NPI: 1184832040
• Name: TIDALHEALTH PENINSULA REGIONAL, INC.
• Entity type: Organization
• Organization Name: TIDALHEALTH PENINSULA REGIONAL, INC.
• Authorized Official - Title/Position: CFO
• Authorized Official - First Name: STEPHANIE
• Authorized Official - Last Name: GARY
• 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
• Enumeration Date: 2007-05-21
• Last Update Date: 2023-02-28

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