Basic Information
| Provider Information | |||||||||
| NPI: | 1053329938 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRIDENT EMERGENCY PHYSICIANS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11450 | ||||||||
| Address2: | |||||||||
| City: | WESTMINSTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005098138 | ||||||||
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| Practice Location | |||||||||
| Address1: | 401 N LIVE OAK DR | ||||||||
| Address2: | |||||||||
| City: | MONCKS CORNER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294615603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437977000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 04/22/2009 | ||||||||
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| AuthorizedOfficialLastName: | OLDFIELD | ||||||||
| AuthorizedOfficialFirstName: | BAIRD | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8437977000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | GP0167 | 05 | SC | MEDICAID |