Provider Demographics
NPI:1245214477
Name:TIDALHEALTH NANTICOKE, INC
Entity type:Organization
Organization Name:TIDALHEALTH NANTICOKE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT-FINANCE/ 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 1:801 MIDDLEFORD RD
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19973-3636
Mailing Address - Country:US
Mailing Address - Phone:302-629-6611
Mailing Address - Fax:302-628-6363
Practice Address - Street 1:801 MIDDLEFORD RD
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:DE
Practice Address - Zip Code:19973-3636
Practice Address - Country:US
Practice Address - Phone:302-629-6611
Practice Address - Fax:302-628-6363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-01
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
291U00000X, 261QP2000X, 261QR0200X
DEHSPTL008282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No291U00000XLaboratoriesClinical Medical Laboratory
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE000067506Medicaid
DE000067105Medicaid