1184832040 NPI number — TIDALHEALTH PENINSULA REGIONAL, INC.

Table of content: REE CHOE (NPI 1598275463)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184832040 NPI number — TIDALHEALTH PENINSULA REGIONAL, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIDALHEALTH PENINSULA REGIONAL, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184832040
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 E CARROLL ST
Provider Second Line Business Mailing Address:
PENINSULA REGIONAL MEDICAL GROUP
Provider Business Mailing Address City Name:
SALISBURY
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21801-5422
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-543-7252
Provider Business Mailing Address Fax Number:
410-912-6386

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 E CARROLL ST
Provider Second Line Business Practice Location Address:
PENINSULA REGIONAL MEDICAL GROUP
Provider Business Practice Location Address City Name:
SALISBURY
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21801-5422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-543-7252
Provider Business Practice Location Address Fax Number:
410-912-6386
Provider Enumeration Date:
05/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GARY
Authorized Official First Name:
STEPHANIE
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
410-912-6059

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RE0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0850X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0855X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CC4271 . This is a "MEDICARE RRB" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: CA8333 . This is a "MEDICARE RRB" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 0000241502 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: C10607 . This is a "MEDICARE PTAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: K230 . This is a "MEDICARE NSC" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: K230 . This is a "MEDICARE PTAN" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 401428600 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: CA8334 . This is a "MEDICARE RRB" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: G01753 . This is a "MEDICARE NSC" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 525701800 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: C10607 . This is a "MEDICARE NSC" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: CC3716 . This is a "MEDICARE RRB" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: G01753 . This is a "MEDICARE PTAN" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".




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