MEDICARE: TRIDENT ANESTHESIA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	R855204	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053713123
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRIDENT ANESTHESIA LLC

Provider Business Mailing Address
First Line	:	2773 SAINT ANDREWS DR
Second Line	:
City	:	BELDEN
State	:	MS
Zip	:	38826-9412
Country	:	US
Telephone Number	:	662-231-8023
Fax Number	:

Provider Business Practice Location Address
First Line	:	2773 SAINT ANDREWS DR
Second Line	:
City	:	BELDEN
State	:	MS
Zip	:	38826-9412
Country	:	US
Telephone Number	:	662-231-8023
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KEVEN BARBER
Credential	:	CRNA
Telephone Number	:	662-231-8023

Provider Enumeration Date	:	09/20/2014
Last Update Date	:	09/20/2014

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