Basic Information
| Provider Information | |||||||||
| NPI: | 1427298629 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TIDALHEALTH PENINSULA REGIONAL, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | TIDALHEALTH FAMILY LAB | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2498 | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218022498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105437437 | ||||||||
| FaxNumber: | 4105437020 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 E CARROLL ST | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218015422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105437437 | ||||||||
| FaxNumber: | 4105437020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2009 | ||||||||
| LastUpdateDate: | 11/16/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GRIFFIN | ||||||||
| AuthorizedOfficialFirstName: | MICKEY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, PFS | ||||||||
| AuthorizedOfficialTelephone: | 4105437437 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CRCE | ||||||||
| NPICertificationDate: | 11/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 22-003 | MD | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 401428600 | 05 | MD | MEDICAID |