SYMPHONY DIAGNOSTIC SERVICES NO 1 LLC

Provider Demographics

• NPI: 1700865094
• Name: SYMPHONY DIAGNOSTIC SERVICES NO 1 LLC
• Entity Type: Organization
• Organization Name: SYMPHONY DIAGNOSTIC SERVICES NO 1 LLC
• Other - Org Name: TRIDENTCARE
• Other - Org Type: Doing Business As
• Authorized Official - Title/Position: AUTHORIZED OFFICIAL/CFO
• Authorized Official - First Name: BRIAN
• Authorized Official - Middle Name: C
• Authorized Official - Last Name: CUOMO
• Authorized Official - Phone: 800-786-8015
• Mailing Address - Street 1: 930 RIDGEBROOK RD
• Mailing Address - Street 2: 3RD FLOOR
• Mailing Address - City: SPARKS
• Mailing Address - State: MD
• Mailing Address - Zip Code: 21152-9390
• Mailing Address - Country: US
• Mailing Address - Phone: 800-786-8015
• Mailing Address - Fax: 443-662-4230
• Practice Address - Street 1: 930 RIDGEBROOK RD
• Practice Address - Street 2: 3RD FLOOR
• Practice Address - City: SPARKS
• Practice Address - State: MD
• Practice Address - Zip Code: 21152-9390
• Practice Address - Country: US
• Practice Address - Phone: 800-786-8015
• Practice Address - Fax: 443-662-4230
• EIN: <UNAVAIL>
• Is Organization Subpart?: Yes
• Parent Organization LBN: SYMPHONY DIAGNOSTIC SERVICES NO 1 LLC
• Parent Organization TIN: <UNAVAIL>
• Enumeration Date: 2006-01-13
• Last Update Date: 2024-04-19

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	335V00000X	Suppliers	Portable X-ray and/or Other Portable Diagnostic Imaging Supplier
No	261QR0208X	Ambulatory Health Care Facilities	Clinic/Center	Radiology, Mobile

Provider Identifiers

State	Identifier ID	ID Type	Issuer
MA	110029440/A	Medicaid
MN	1700865094	Medicaid
KY	86000247	Medicaid
TN	1519090	Medicaid
NH	3085730	Medicaid
RI	9419801	Medicaid
DC	034072900	Medicaid
OH	0896268	Medicaid
IA	1700865094	Medicaid
NJ	7519206	Medicaid
IN	100121370A	Medicaid
OK	100836640C	Medicaid
AL	100968	Medicaid
ID	1013217769	Medicaid
DE	25069365	Medicaid
KS	100365530A	Medicaid
MI	1700865094	Medicaid
LA	2374656	Medicaid
WV	3910006821	Medicaid
MD	415092900	Medicaid
NM	B7883	Medicaid
NY	03373273	Medicaid
CT	004222098	Medicaid
ME	19423000	Medicaid
NC	3419804	Medicaid
VA	4980867	Medicaid
FL	510055100	Medicaid
CO	9000189649	Medicaid
PA	001485908-0006	Medicaid
GA	00320-5515A	Medicaid
MS	03106321	Medicaid
TX	086063701	Medicaid
AZ	095566	Medicaid
VT	1006117	Medicaid
WI	42506100	Medicaid
SC	498152	Medicaid
MO	711934307	Medicaid
MI	OP39500	Medicare PIN
SC	Q330380001	Medicare PIN
IL	149867	Medicare PIN
UT	000090700	Medicare PIN
DC	314150	Medicare PIN