Basic Information
| Provider Information | |||||||||
| NPI: | 1366496937 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRIDENT MEDICAL CENTER LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | TRIDENT MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 9330 MEDICAL PLAZA DR | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294069104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438477000 | ||||||||
| FaxNumber: | 8438474086 | ||||||||
| Practice Location | |||||||||
| Address1: | 9330 MEDICAL PLAZA DR | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294069104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438477000 | ||||||||
| FaxNumber: | 8438474086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 05/28/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | ANDY | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8438474100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 1004107 | 05 | MA | MEDICAID | 166376800 | 01 | DEPT OF LABOR | OTHER | 733728 | 05 | OH | MEDICAID | 909075400 | 05 | FL | MEDICAID | 00096542 | 05 | MS | MEDICAID | 00881944X | 05 | GA | MEDICAID | 01601129 | 05 | KY | MEDICAID | 1000037000 | 05 | DE | MEDICAID | 1537918 | 01 | UNITED MINE WORKERS | OTHER | 269338 | 05 | SC | MEDICAID | 3025186 | 05 | WA | MEDICAID | 032516900 | 05 | DC | MEDICAID | 100506046 | 05 | NV | MEDICAID | 5000221 | 01 | PHYSICIANS HEALTH PLAN | OTHER | 81237100 | 05 | WI | MEDICAID | XHSP33273 | 05 | CA | MEDICAID | 10043717 | 01 | GATEWAY MEDICAID | OTHER | 200357120A | 05 | KS | MEDICAID | 272545 | 01 | BLACK LUNG | OTHER | 30696 | 05 | PA | MEDICAID | 10025100800 | 05 | NE | MEDICAID | 978634 | 05 | NY | MEDICAID | 420079 | 01 | HIGHMARK BLUE CROSS | OTHER | 4200799 | 05 | VA | MEDICAID | 016119109 | 05 | MO | MEDICAID | 1745936 | 05 | LA | MEDICAID | 304744932 | 05 | MI | MEDICAID | 4212304 | 05 | NJ | MEDICAID | 6699 | 01 | BLUE CARE | OTHER | 873192 | 05 | AZ | MEDICAID | 100698030A | 05 | OK | MEDICAID | 158181105 | 05 | AR | MEDICAID | 200241300A | 05 | IN | MEDICAID | 4200790 | 05 | RI | MEDICAID | TRI0079N | 05 | AL | MEDICAID |