Provider Demographics
NPI:1912324658
Name:TIDALHEALTH PHYSICIAN NETWORK, INC.
Entity Type:Organization
Organization Name:TIDALHEALTH PHYSICIAN NETWORK, INC.
Other - Org Name:NANTICOKE IMMEDIATE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR DIRECTOR OF FINANCE
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:JESTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-629-6611
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:302-629-5217
Mailing Address - Fax:302-629-9837
Practice Address - Street 1:100 RAWLINS DR
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:DE
Practice Address - Zip Code:19973-5881
Practice Address - Country:US
Practice Address - Phone:302-536-5415
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-19
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEHSPTL-008207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty