Provider Demographics
NPI:1740394071
Name:TRIDENT MEDICAL SERVICES D/B/A TRIDENT SENIOR HEALTH CENTER
Entity Type:Organization
Organization Name:TRIDENT MEDICAL SERVICES D/B/A TRIDENT SENIOR HEALTH CENTER
Other - Org Name:TRIDENT SENIOR HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DENMARK
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:843-797-0416
Mailing Address - Street 1:9302 MEDICAL PLAZA DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9142
Mailing Address - Country:US
Mailing Address - Phone:843-797-0416
Mailing Address - Fax:843-847-4477
Practice Address - Street 1:9302 MEDICAL PLAZA DR
Practice Address - Street 2:SUITE C
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9142
Practice Address - Country:US
Practice Address - Phone:843-797-0416
Practice Address - Fax:843-847-4477
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRIDENT MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-17
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1196Medicaid
SC4856Medicare PIN
CH6021Medicare PIN