Provider Demographics
NPI:1306507579
Name:TIDALHEALTH PENINSULA REGIONAL, INC.
Entity type:Organization
Organization Name:TIDALHEALTH PENINSULA REGIONAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. VICE PRESIDENT/CFO
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:ISHMAEL
Authorized Official - Last Name:RITCHIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-543-7298
Mailing Address - Street 1:PO BOX 826880
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-6880
Mailing Address - Country:US
Mailing Address - Phone:410-912-6989
Mailing Address - Fax:
Practice Address - Street 1:201 HALL HWY
Practice Address - Street 2:
Practice Address - City:CRISFIELD
Practice Address - State:MD
Practice Address - Zip Code:21817-1237
Practice Address - Country:US
Practice Address - Phone:410-968-1200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health