Provider Demographics
NPI:1235533480
Name:TRIDENT PAIN CENTER, PA
Entity Type:Organization
Organization Name:TRIDENT PAIN CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:NOLAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-797-3636
Mailing Address - Street 1:9267 MEDICAL PLAZA DR STE G
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9139
Mailing Address - Country:US
Mailing Address - Phone:843-797-3636
Mailing Address - Fax:843-797-3637
Practice Address - Street 1:1341 OLD GEORGETOWN RD
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-7307
Practice Address - Country:US
Practice Address - Phone:843-797-3636
Practice Address - Fax:843-797-3637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-17
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3479Medicaid
SCGP3479Medicaid