NPIMap

Organization Active NPI

Tidalhealth Peninsula Regional, Inc.

  • Family Medicine Physician
  • Salisbury, MD
National Provider Identifier
1184832040
Registry record updated Feb 28, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
TIDALHEALTH PENINSULA REGIONAL, INC.
Practice address
100 E Carroll St
Peninsula Regional Medical Group
Salisbury, MD 21801-5422
Phone
(410) 543-7252
Fax
(410) 912-6386
NPI assigned
May 21, 2007
Last updated
Feb 28, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 28, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Stephanie Gary
Title
Cfo
Phone
(410) 912-6059

Specialties & licenses 15

Specialty (taxonomy)CodeLicenseStatePrimary
Emergency Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207P00000X
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X Primary
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X
Endocrinology, Diabetes & Metabolism PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207RE0101X
Gastroenterology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207RG0100X
Hematology & Oncology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207RH0003X
Pulmonary Disease PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207RP1001X
Neurological Surgery PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207T00000X
Pediatrics PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208000000X
General Practice PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208D00000X
Thoracic Surgery (Cardiothoracic Vascular Surgery) PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208G00000X
Adult Mental Health Clinic/Center 261QM0850X
Adolescent and Children Mental Health Clinic/Center 261QM0855X
Physician AssistantGroup: 193200000X MULTI-SPECIALTY GROUP 363A00000X
Family Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LF0000X

Addresses

Primary practice location

100 E Carroll St
Peninsula Regional Medical Group
Salisbury, MD 21801-5422

Mailing address

100 E Carroll St
Peninsula Regional Medical Group
Salisbury, MD 21801-5422
Phone (410) 543-7252

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MD

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040420001571 MD Part B Supplier - Clinic/Group Practice 3072509702 Receives reassigned benefits from 212 practitioners
2 other NPIs on this enrollment
Practice locations: Salisbury, MD; Berlin, MD

Other NPIs with the same Medicare PAC ID 5

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Locations

35786 Atlantic Ave
Millville, DE 19967
Phone (302) 676-8307

630051 Box
Baltimore, MD 21263

500 Market St
Ste 101
Pocomoke City, MD 21851
Phone (410) 957-1311

100 E Carroll St
Rm 3304
Salisbury, MD 21801

1415 S Division St
Salisbury, MD 21804
Phone (410) 572-8848

Practitioners & affiliated clinicians

Practitioners 215

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 215

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1179705600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1677542400000",
    "number": "1184832040",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "100 E CARROLL ST",
            "address_2": "PENINSULA REGIONAL MEDICAL GROUP",
            "city": "SALISBURY",
            "state": "MD",
            "postal_code": "218015422",
            "telephone_number": "410-543-7252",
            "fax_number": "410-912-6386"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 E CARROLL ST",
            "address_2": "PENINSULA REGIONAL MEDICAL GROUP",
            "city": "SALISBURY",
            "state": "MD",
            "postal_code": "218015422",
            "telephone_number": "410-543-7252",
            "fax_number": "410-912-6386"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TIDALHEALTH PENINSULA REGIONAL, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-05-21",
        "last_updated": "2023-02-28",
        "certification_date": "2023-02-28",
        "status": "A",
        "authorized_official_last_name": "GARY",
        "authorized_official_first_name": "STEPHANIE",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "410-912-6059"
    },
    "taxonomies": [
        {
            "code": "207P00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Emergency Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207RE0101X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine, Endocrinology, Diabetes & Metabolism",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207RG0100X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine, Gastroenterology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207RH0003X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine, Hematology & Oncology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207RP1001X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine, Pulmonary Disease",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207T00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Neurological Surgery",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208D00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "General Practice",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208G00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Thoracic Surgery (Cardiothoracic Vascular Surgery)",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QM0850X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adult Mental Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QM0855X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adolescent and Children Mental Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Salisbury, MD

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 28, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.