Provider Demographics
NPI:1780882928
Name:TRIDICO, JAMIE L
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:L
Last Name:TRIDICO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 MACCORKLE AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-2503
Mailing Address - Country:US
Mailing Address - Phone:304-720-9185
Mailing Address - Fax:304-720-9186
Practice Address - Street 1:4301 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-2503
Practice Address - Country:US
Practice Address - Phone:304-720-9185
Practice Address - Fax:304-720-9186
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1220225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810009418Medicaid
WVQ38448AMedicare PIN
WV3810009418Medicaid
1037690001Medicare NSC
WV9301591Medicare PIN