1487954913 NPI number — AMERICAN DIAGNOSTICS SERVICES LLC

Table of content: (NPI 1487954913)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487954913 NPI number — AMERICAN DIAGNOSTICS SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMERICAN DIAGNOSTICS SERVICES 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:
TRIDENTCARE
Provider Other Organization Name Type Code:
3
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:
1487954913
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
930 RIDGEBROOK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPARKS
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21152-9481
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-406-0310
Provider Business Mailing Address Fax Number:
410-472-1754

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
930 RIDGEBROOK RD FL 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPARKS GLENCOE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21152-9481
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-786-8015
Provider Business Practice Location Address Fax Number:
410-472-1754
Provider Enumeration Date:
11/01/2010

Additional Information

Authorized Official

Authorized Official Last Name:
CUOMO
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
C
Authorized Official Title or Position:
AUTHORIZED OFFICIAL/CFO
Authorized Official Telephone Number:
800-786-8015

Provider Taxonomy Codes

  • Taxonomy code: 293D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1487954913 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10026119900 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1487954913 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00972855 . This is a "RR MEDICARE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: P01101435 . This is a "RR MEDICARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 03340952 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3910006905 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01101462 . This is a "RR MEDICARE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: P01101442 . This is a "RR MEDICARE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: P01101464 . This is a "RR MEDICARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: P01107140 . This is a "RR MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2400109010A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3106321 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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