Provider Demographics
NPI:1902204191
Name:TRIDENT CLINICAL PLLC
Entity Type:Organization
Organization Name:TRIDENT CLINICAL PLLC
Other - Org Name:TRIDENT HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ARVIND
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHADEVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-241-2034
Mailing Address - Street 1:20340 N LAKE PLEASANT RD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-9714
Mailing Address - Country:US
Mailing Address - Phone:623-299-9988
Mailing Address - Fax:
Practice Address - Street 1:20340 N LAKE PLEASANT RD STE 109
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-9713
Practice Address - Country:US
Practice Address - Phone:623-299-9988
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-20
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ40752261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ125634Medicare PIN