1801038260 NPI number — TIDALHEALTH SPECIALTY CARE, LLC

Table of content: (NPI 1801038260)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801038260 NPI number — TIDALHEALTH SPECIALTY CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIDALHEALTH SPECIALTY CARE, LLC
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:
1801038260
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:
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:
410-543-7272
Provider Business Mailing Address Fax Number:
410-912-6386

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30265 COMMERCE DR UNIT 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILLSBORO
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19966-3594
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-990-3280
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/01/2009

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: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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