Basic Information
| Provider Information | |||||||||
| NPI: | 1013532969 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TIDALHEALTH SPECIALTY CARE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2498 | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218022498 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 560 RIVERSIDE DR STE A206 | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218014704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109125640 | ||||||||
| FaxNumber: | 4109125787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2020 | ||||||||
| LastUpdateDate: | 06/16/2020 | ||||||||
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| AuthorizedOfficialLastName: | DIBARI | ||||||||
| AuthorizedOfficialFirstName: | KARIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6035772799 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TIDALHEALTH SPECIALTY CARE, LLC | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.