1871031559 NPI number — TIDALHEALTH PENINSULA REGIONAL, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871031559 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:
6
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:
1871031559
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1620 W. NORTHWEST HWY
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
GRAPEVINE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76051
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-572-0009
Provider Business Mailing Address Fax Number:
817-572-0221

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 E. CARROLL STREET
Provider Second Line Business Practice Location Address:
SUITE 1435A
Provider Business Practice Location Address City Name:
SALISBURY
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
667-330-1065
Provider Business Practice Location Address Fax Number:
410-438-1992
Provider Enumeration Date:
02/02/2017

Additional Information

Authorized Official

Authorized Official Last Name:
JORDAN
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
SR. DIRECTOR OF PHARMACY
Authorized Official Telephone Number:
410-749-2825

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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