Healthcare Provider Details

I. General information

NPI: 1083368831
Provider Name (Legal Business Name): TRIDENT MEDICAL GROUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2022
Last Update Date: 11/14/2022
Certification Date: 11/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10440 LITTLE PATUXENT PKWY STE 300
COLUMBIA MD
21044-3648
US

IV. Provider business mailing address

382 NE 191ST ST
MIAMI FL
33179-3899
US

V. Phone/Fax

Practice location:
  • Phone: 855-770-7771
  • Fax: 415-808-6405
Mailing address:
  • Phone: 310-626-0149
  • Fax: 415-808-6405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213EP0504X
TaxonomyPublic Medicine Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: DEVION SMITH
Title or Position: DIRECTOR, PAYER CONTRACTING
Credential:
Phone: 424-326-8711