Basic Information
| Provider Information | |||||||||
| NPI: | 1174724991 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TIDALHEALTH PENINSULA REGIONAL, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TIDALHEALTH COVID INFUSION CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 826880 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191825454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105466400 | ||||||||
| FaxNumber: | 4109124959 | ||||||||
| Practice Location | |||||||||
| Address1: | 145 E CARROLL ST | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218015454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105466400 | ||||||||
| FaxNumber: | 4109124959 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2007 | ||||||||
| LastUpdateDate: | 01/06/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GRIFFIN | ||||||||
| AuthorizedOfficialFirstName: | MICKEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4105437437 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QI0500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Infusion Therapy |
No ID Information.