1699435081 NPI number — TRIDENT MEDICAL GROUP PA

Table of content: (NPI 1699435081)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699435081 NPI number — TRIDENT MEDICAL GROUP PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRIDENT MEDICAL GROUP PA
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:
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:
1699435081
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
382 NE 191ST ST, PMB 75481
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33179-3899
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-626-0149
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3372 PEACHTREE ROAD
Provider Second Line Business Practice Location Address:
SUITE 115
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-770-7771
Provider Business Practice Location Address Fax Number:
415-808-6405
Provider Enumeration Date:
12/27/2021

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
DEVION
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR, PAYER CONTRACTING
Authorized Official Telephone Number:
424-326-8711

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213EP0504X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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