Provider Demographics
NPI:1427298629
Name:TIDALHEALTH PENINSULA REGIONAL, INC.
Entity type:Organization
Organization Name:TIDALHEALTH PENINSULA REGIONAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, PFS
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICKEY
Authorized Official - Middle Name:M
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:CRCE
Authorized Official - Phone:410-543-7437
Mailing Address - Street 1:PO BOX 2498
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21802-2498
Mailing Address - Country:US
Mailing Address - Phone:410-543-7437
Mailing Address - Fax:410-543-7020
Practice Address - Street 1:100 E CARROLL ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-5422
Practice Address - Country:US
Practice Address - Phone:410-543-7437
Practice Address - Fax:410-543-7020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-27
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22-003291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD401428600Medicaid