Provider Demographics
NPI:1154757482
Name:TRIDENT PAIN CENTER LLC
Entity type:Organization
Organization Name:TRIDENT PAIN CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:NOLAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-797-3636
Mailing Address - Street 1:9267 MEDICAL PLAZA DR STE G
Mailing Address - Street 2:
Mailing Address - City:N CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9139
Mailing Address - Country:US
Mailing Address - Phone:843-797-3636
Mailing Address - Fax:843-797-3637
Practice Address - Street 1:108 N HIGHWAY 52
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-3910
Practice Address - Country:US
Practice Address - Phone:843-797-3636
Practice Address - Fax:843-797-3637
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRIDENT PAIN CENTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-09-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3479Medicaid
SC7439Medicare PIN