Provider Demographics
NPI:1699435081
Name:TRIDENT MEDICAL GROUP PA
Entity type:Organization
Organization Name:TRIDENT MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, PAYER CONTRACTING
Authorized Official - Prefix:
Authorized Official - First Name:DEVION
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:424-326-8711
Mailing Address - Street 1:382 NE 191ST ST, PMB 75481
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33179-3899
Mailing Address - Country:US
Mailing Address - Phone:310-626-0149
Mailing Address - Fax:
Practice Address - Street 1:3372 PEACHTREE ROAD
Practice Address - Street 2:SUITE 115
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30326
Practice Address - Country:US
Practice Address - Phone:855-770-7771
Practice Address - Fax:415-808-6405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-27
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213EP0504XPodiatric Medicine & Surgery Service ProvidersPodiatristPublic MedicineGroup - Multi-Specialty