Provider Demographics
NPI:1215237839
Name:TRIDENT MEDICAL MANAGEMENT, INC.
Entity type:Organization
Organization Name:TRIDENT MEDICAL MANAGEMENT, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AKINWUMI
Authorized Official - Middle Name:GAMMAL
Authorized Official - Last Name:ALADESAWE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-842-6900
Mailing Address - Street 1:6131 US HIGHWAY 19
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652-2527
Mailing Address - Country:US
Mailing Address - Phone:727-842-6900
Mailing Address - Fax:727-842-6902
Practice Address - Street 1:6131 US HIGHWAY 19
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-2527
Practice Address - Country:US
Practice Address - Phone:727-842-6900
Practice Address - Fax:727-842-6902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-29
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME112766261QP2300X, 261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care