Basic Information
| Provider Information | |||||||||
| NPI: | 1376595520 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRIDENT ANESTHESIA GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9263 MEDICAL PLAZA DR. | ||||||||
| Address2: | STE E | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294067112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435721228 | ||||||||
| FaxNumber: | 8775617564 | ||||||||
| Practice Location | |||||||||
| Address1: | 9263 MEDICAL PLAZA DR. | ||||||||
| Address2: | STE E | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294067112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435721228 | ||||||||
| FaxNumber: | 8775617564 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 06/20/2012 | ||||||||
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| AuthorizedOfficialLastName: | FISHMAN | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8435721228 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | GP0090 | 05 | SC | MEDICAID |