Basic Information
| Provider Information | |||||||||
| NPI: | 1306507579 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TIDALHEALTH PENINSULA REGIONAL, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 826880 | ||||||||
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| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191826880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109126989 | ||||||||
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| Practice Location | |||||||||
| Address1: | 201 HALL HWY | ||||||||
| Address2: | |||||||||
| City: | CRISFIELD | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218171237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109681200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2022 | ||||||||
| LastUpdateDate: | 01/10/2022 | ||||||||
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| AuthorizedOfficialLastName: | RITCHIE | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
| AuthorizedOfficialMiddleName: | ISHMAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | SR. VICE PRESIDENT/CFO | ||||||||
| AuthorizedOfficialTelephone: | 4105437298 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QM0850X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
No ID Information.