Provider Demographics
NPI:1871582171
Name:ATLANTIC GENERAL HOSPITAL CORPORATION
Entity type:Organization
Organization Name:ATLANTIC GENERAL HOSPITAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SVP, FINANCE/CFO OF TIDALHEALTH
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 1:9733 HEALTHWAY DR # 41
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-1155
Mailing Address - Country:US
Mailing Address - Phone:410-629-6037
Mailing Address - Fax:410-629-1194
Practice Address - Street 1:10026 OLD OCEAN CITY BLVD STE 1
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-1288
Practice Address - Country:US
Practice Address - Phone:410-641-9450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ATLANTIC GENERAL HOSPITAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-19
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD207R00000X, 207RP1001X, 208000000X, 207V00000X, 208600000X, 207L00000X, 208M00000X, 261QX0200X, 363L00000X, 207Q00000X
207RH0003X, 261QM1300X, 261QR0200X, 261QR0206X, 261QR0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty
No261QX0200XAmbulatory Health Care FacilitiesClinic/CenterOncologyGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiologyGroup - Single Specialty
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, MammographyGroup - Single Specialty
No261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, MobileGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE250610237Medicaid
MDE707OtherCAREFIRST MD GROUP
MD514300400Medicaid