Provider Demographics
NPI:1275293078
Name:TRIDENT MEDICAL GROUP PA
Entity Type:Organization
Organization Name:TRIDENT MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, PAYER CONTRACTING
Authorized Official - Prefix:
Authorized Official - First Name:DEVION
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:424-326-8711
Mailing Address - Street 1:382 NE 191ST ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33179-3899
Mailing Address - Country:US
Mailing Address - Phone:310-626-0149
Mailing Address - Fax:
Practice Address - Street 1:325 N SAINT PAUL ST STE 3100
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75201-3923
Practice Address - Country:US
Practice Address - Phone:855-770-7771
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-21
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213EP0504XPodiatric Medicine & Surgery Service ProvidersPodiatristPublic MedicineGroup - Multi-Specialty