Provider Demographics
NPI:1043984115
Name:TRIDENT MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:TRIDENT MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NARESH
Authorized Official - Middle Name:
Authorized Official - Last Name:BASSI
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACP, FHM
Authorized Official - Phone:703-509-9198
Mailing Address - Street 1:42115 PEMBERLY CT
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20152-5982
Mailing Address - Country:US
Mailing Address - Phone:703-509-9198
Mailing Address - Fax:
Practice Address - Street 1:19415 DEERFIELD AVE STE 103
Practice Address - Street 2:
Practice Address - City:LANSDOWNE
Practice Address - State:VA
Practice Address - Zip Code:20176-8470
Practice Address - Country:US
Practice Address - Phone:703-509-9198
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-03
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty