AMERICAN DIAGNOSTICS SERVICES LLC
Complete NPI Record 1639140387
Physiological Laboratory in Windsor Mill, MD

Active since January 31, 2006

2505 LORD BALTIMORE DRIVE, SUITE E, WINDSOR MILL, MD 21244(410) 295-3565(443) 842-7264 Get Directions

NPPES record last updated: March 11, 2026. Verified against the NPPES registry weekly; last sync: October 04, 2026.

Record update history: Mar 11, 2026, Feb 4, 2026, Aug 11, 2025 and 5 more (8 updates tracked since 2017).

Complete NPI Dataset

This page contains the complete raw NPPES record for American Diagnostics Services Llc (NPI 1639140387), a physiological laboratory organization in Windsor Mill, MD. All 141 fields on file are listed with their current values and official NPPES definitions, exactly as recorded in the National Plan and Provider Enumeration System. Only fields that contain data are included, so the number of fields shown varies from one NPI record to another.

Use the tools below to filter fields by category, search within the record, or jump straight to a specific field. You can download the full record as a CSV, JSON, Markdown or text file, or filter first and export only the fields you need. The Print Clean Summary button produces a printer-friendly copy of the record.

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NPI: 1639140387: The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
Entity Type Code: 2: Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
Employer Identification Number EIN: Not available: The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified.
Provider Organization Name Legal Business Name: AMERICAN DIAGNOSTICS SERVICES LLC: The name of the organization provider. If the provider is an organization, this is the legal business name.
Provider Other Organization Name: Not available: Other name by which the organization provider is or has been known.
Provider Other Organization Name Type Code: 6: Code identifying the type of other name. Codes are: 1 = former name; 2 = professional name; 3 = doing business as (d/b/ a) name; 4 = former legal business name; 5 = other.
Provider First Line Business Mailing Address: 215 SCHILLING CIR STE 114: The first line mailing address of the provider being identified. This data element may contain the same information as "Provider first line location address".
Provider Business Mailing Address City Name: HUNT VALLEY: The city name in the mailing address of the provider being identified.
Provider Business Mailing Address State Name: MD: The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as "Provider location address State name".
Provider Business Mailing Address Postal Code: 210311113: The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as "Provider location address postal code".
Provider Business Mailing Address Country Code If outside U S : US: The country code in the mailing address of the provider being identified. This data element may contain the same information as "Provider location address country code".
Provider Business Mailing Address Telephone Number: 8007868015: The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as "Provider location address telephone number".
Provider Business Mailing Address Fax Number: 4104721754: The fax number associated with the mailing address of the provider being identified. This data element may contain the same information as "Provider location address fax number".
Provider First Line Business Practice Location Address: 2505 LORD BALTIMORE DRIVE: The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
Provider Second Line Business Practice Location Address: SUITE E: The second line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
Provider Business Practice Location Address City Name: WINDSOR MILL: The city name in the location address of the provider being identified.
Provider Business Practice Location Address State Name: MD: The State code in the location of the provider being identified.
Provider Business Practice Location Address Postal Code: 212442639: The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
Provider Business Practice Location Address Country Code If outside U S : US: The country code in the location address of the provider being identified.
Provider Business Practice Location Address Telephone Number: 4102953565: The telephone number associated with the location address of the provider being identified.
Provider Business Practice Location Address Fax Number: 4438427264: The fax number associated with the location address of the provider being identified.
Provider Enumeration Date: 1/31/2006: The date the provider was assigned a unique identifier (assigned an NPI).
Last Update Date: 3/11/2026: The date that a record was last updated or changed.
Authorized Official Last Name: CUOMO: The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
Authorized Official First Name: BRIAN: The first name of the authorized official.
Authorized Official Middle Name: C: The middle name of the authorized official.
Authorized Official Title or Position: AUTHORIZED OFFICIAL/CFO: The title or position of the authorized official.
Authorized Official Telephone Number: 8007868015: The 10-position telephone number of the authorized official.
Healthcare Provider Taxonomy Code 1: 2085R0202X: This field represents the provider's taxonomy code, which classifies their type, classification, and area of specialization. This code comes from the Healthcare Provider Taxonomy Code Set maintained by the National Uniform Claim Committee (NUCC). The NPS will associate these data with the license data for providers with Entity type code = 1.
Healthcare Provider Primary Taxonomy Switch 1: N: This field shows whether the related taxonomy code is the provider's primary specialty. It is a single-character value: "Y" indicates the taxonomy is the primary one, while "N" indicates it is not. Each provider record can have only one taxonomy code marked as primary.
Healthcare Provider Taxonomy Code 2: 293D00000X: This field represents the provider's taxonomy code, which classifies their type, classification, and area of specialization. This code comes from the Healthcare Provider Taxonomy Code Set maintained by the National Uniform Claim Committee (NUCC). The NPS will associate these data with the license data for providers with Entity type code = 1.
Healthcare Provider Primary Taxonomy Switch 2: Y: This field shows whether the related taxonomy code is the provider's primary specialty. It is a single-character value: "Y" indicates the taxonomy is the primary one, while "N" indicates it is not. Each provider record can have only one taxonomy code marked as primary.
Other Provider Identifier 1: 1487954913: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 1: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 1: MN: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 2: 1639140387: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 2: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 2: MI: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 3: 19531: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 3: 01: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 3: PA: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier Issuer 3: HEALTH/SENIOR PARTNERS: The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
Other Provider Identifier 4: 250540997: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 4: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 4: DE: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 5: 417010500: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 5: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 5: MD: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 6: 119726: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 6: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 6: AL: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 7: 1523253: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 7: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 7: TN: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 8: 2839585: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 8: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 8: OH: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 9: 91000047800: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 9: 01: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 9: NJ: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier Issuer 9: AMERICHOICE: The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
Other Provider Identifier 10: 200726830A: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 10: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 10: KS: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 11: 200980860A: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 11: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 11: IN: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 12: 1639140387: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 12: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 12: MO: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 13: 200409010A: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 13: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 13: OK: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 14: 1639140387: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 14: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 14: PA: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 15: 1639140387: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 15: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 15: VA: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 16: 2563931: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 16: 01: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 16: PA: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier Issuer 16: AETNA: The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
Other Provider Identifier 17: 1035442: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 17: 01: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 17: NJ: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier Issuer 17: HORIZON MERCEY: The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
Other Provider Identifier 18: 118225200: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 18: 01: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 18: NJ: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier Issuer 18: DEPT. OF LABOR: The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
Other Provider Identifier 19: 1487954913: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 19: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 19: IA: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 20: 7100156790: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 20: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 20: KY: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 21: 0015026330013: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 21: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 21: PA: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 22: 03340952: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 22: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 22: NY: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 23: 0389137000: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 23: 01: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 23: PA: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier Issuer 23: AMERIHEALTH: The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
Other Provider Identifier 24: 0389137000: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 24: 01: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 24: PA: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier Issuer 24: IBC: The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
Other Provider Identifier 25: 10661: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 25: 01: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 25: PA: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier Issuer 25: ELDERHEALTH: The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
Other Provider Identifier 26: 3081146: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 26: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 26: NH: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 27: 3910006905: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 27: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 27: WV: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 28: 038913700: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 28: 01: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 28: PA: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier Issuer 28: KEYSTONE: The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
Other Provider Identifier 29: 10026119900: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 29: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 29: NE: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 30: 499596: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 30: 01: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 30: NJ: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier Issuer 30: AETNA: The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
Other Provider Identifier 31: 7660804: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 31: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 31: NJ: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 32: SL0101: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 32: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 32: SC: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Is Organization Subpart: N: Indicates whether the provider is a subpart of a larger organization. This is a single-character code: "Y" means the entity is an organizational subpart, while "N" means it is not. Subparts typically include hospital departments, clinics, or other distinct units that fall under a parent organization.
Healthcare Provider Taxonomy Group 1: 193200000X MULTI-SPECIALTY GROUP: Specifies whether the provider is part of a single-specialty or multi-specialty business group. The possible values are: 193200000X – Multi-Specialty Group or 193400000X – Single Specialty Group. This field helps distinguish the organizational structure of a provider group.
NPI Certification Date: 3/11/2026: The date on which the National Provider Identifier (NPI) was officially assigned and certified to the provider. This reflects when the provider's NPI record first became active in the NPPES system.

Other Organization Names 1

Additional business and trade names this provider has on file with the NPPES registry.

TridentCare Doing Business As

1/1

Doing Business As: A trade name or operating name under which an organization provides services, distinct from its registered legal business name.

Secondary Practice Locations 32

The first line of the secondary practice location address of the provider being identified. For providers with more than one physical location, this is a secondary practice location address. This address cannot include a Post Office box.

95-202 Halepio Pl

1/32

Mililani, HI 96789-5552 · Phone (800) 786-8015 · Fax (443) 842-7264

7700 Brush Hill Rd

2/32

Burr Ridge, IL 60527-7544 · Phone (630) 521-1010 · Fax (602) 343-5856

1660 E Main St Ste 105

3/32

Plainfield, IN 46168-1863 · Phone (317) 839-2117 · Fax (443) 842-7264

460 Smith St Ste A

4/32

Middletown, CT 06457-1594 · Phone (860) 398-5454 · Fax (443) 842-7264

3418 Midcourt Rd Ste 105

5/32

Carrollton, TX 75006-4944 · Phone (800) 786-8015 · Fax (443) 842-7264

301 S Perimeter Park Dr Ste 121

6/32

Nashville, TN 37211-4128 · Phone (615) 333-0904 · Fax (443) 842-7264

1134 Industry Dr

7/32

Tukwila, WA 98188-4803 · Phone (800) 786-8015 · Fax (443) 842-7264

133 Fleming St

8/32

Piscataway, NJ 08854-3350 · Phone (732) 752-9408 · Fax (443) 842-7264

4400 140th Ave N Ste 200-230

9/32

Clearwater, FL 33762-3832 · Phone (800) 786-8015 · Fax (443) 842-7264

2550 Corporate Exchange Dr Ste 15

10/32

Columbus, OH 43231-1660 · Phone (614) 431-5455 · Fax (443) 842-7264

1206 Hartford Ave Ste F

11/32

Johnston, RI 02919-7131 · Phone (401) 831-8343 · Fax (443) 842-7264

3801 Computer Dr Ste 103A

12/32

Raleigh, NC 27609-6506 · Phone (800) 786-8015 · Fax (443) 842-7264

836 Candia Rd

13/32

Manchester, NH 03109-5203 · Phone (207) 773-4199 · Fax (443) 842-7264

7010 S Yale Ave Ste 106

14/32

Tulsa, OK 74136-5702 · Phone (539) 867-4348

115 Gibraltar Rd

15/32

Horsham, PA 19044-2303 · Phone (215) 957-1280 · Fax (443) 842-7264

7355 Prairie Falcon Rd

16/32

Las Vegas, NV 89128-0801 · Phone (800) 786-8015 · Fax (443) 842-7264

5766 Carmichael Pkwy

17/32

Montgomery, AL 36117-2351 · Phone (443) 662-4101 · Fax (443) 842-7264

965 E Yosemite Ave Ste 24

18/32

Manteca, CA 95336-5944 · Phone (800) 786-8015 · Fax (443) 842-7264

2141 S El Camino Real Ste A&b

19/32

Oceanside, CA 92054-9003 · Phone (800) 786-8015 · Fax (443) 842-7264

3223 Sunset Blvd Ste 100

20/32

West Columbia, SC 29169-3200 · Phone (803) 772-2411 · Fax (443) 842-7264

2116 Dabney Rd Ste A1

21/32

Richmond, VA 23230-3341 · Phone (804) 213-9712 · Fax (443) 842-7264

20 Technology Dr Ste M2

22/32

Brattleboro, VT 05301-9181 · Phone (802) 257-9960 · Fax (443) 842-7264

2502 E University Dr Ste 290

23/32

Phoenix, AZ 85034-6932 · Phone (800) 786-8015 · Fax (443) 842-7264

1109 Middleford Rd Ste A

24/32

Seaford, DE 19973-3607 · Phone (302) 628-4209 · Fax (443) 842-7264

9110 Leesgate Rd Ste 6

25/32

Louisville, KY 40222-5053 · Phone (502) 749-1723 · Fax (443) 842-7264

1001 Virginia Ave Ste 302

26/32

Hapeville, GA 30354-1367 · Phone (404) 763-7999 · Fax (443) 842-7264

2 Jonathan Dr

27/32

Brockton, MA 02301-5549 · Phone (508) 313-0070 · Fax (443) 842-7264

891 Brighton Ave Ste 32nd

28/32

Portland, ME 04102-1056 · Phone (207) 253-2446 · Fax (443) 842-7264

21900 Melrose Ave Ste 1

29/32

Southfield, MI 48075-7967 · Phone (248) 948-7939 · Fax (443) 842-7264

7776 S Pointe Pkwy W Ste 150A

30/32

Phoenix, AZ 85044-5427 · Phone (800) 786-8015

10580 Barkley St Ste 415

31/32

Overland Park, KS 66212-1850 · Phone (913) 901-0140 · Fax (443) 842-7264

11012 Lin Valle Dr Ste G

32/32

Saint Louis, MO 63123-7217 · Phone (314) 487-2364 · Fax (443) 842-7264

Other Provider Identifiers 32

Legacy and payer-issued identifiers reported to the NPPES registry for this provider.

1487954913 Medicaid

1/32

State: MN
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

1639140387 Medicaid

2/32

State: MI
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

19531 Other

3/32

State: PA · Issuer: Health/senior Partners
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.

250540997 Medicaid

4/32

State: DE
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

417010500 Medicaid

5/32

State: MD
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

119726 Medicaid

6/32

State: AL
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

1523253 Medicaid

7/32

State: TN
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

2839585 Medicaid

8/32

State: OH
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

91000047800 Other

9/32

State: NJ · Issuer: Americhoice
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.

200726830A Medicaid

10/32

State: KS
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

200980860A Medicaid

11/32

State: IN
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

1639140387 Medicaid

12/32

State: MO
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

200409010A Medicaid

13/32

State: OK
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

1639140387 Medicaid

14/32

State: PA
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

1639140387 Medicaid

15/32

State: VA
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

2563931 Other

16/32

State: PA · Issuer: Aetna
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.

1035442 Other

17/32

State: NJ · Issuer: Horizon Mercey
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.

118225200 Other

18/32

State: NJ · Issuer: Dept. Of Labor
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.

1487954913 Medicaid

19/32

State: IA
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

7100156790 Medicaid

20/32

State: KY
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

0015026330013 Medicaid

21/32

State: PA
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

03340952 Medicaid

22/32

State: NY
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

0389137000 Other

23/32

State: PA · Issuer: Amerihealth
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.

0389137000 Other

24/32

State: PA · Issuer: Ibc
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.

10661 Other

25/32

State: PA · Issuer: Elderhealth
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.

3081146 Medicaid

26/32

State: NH
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

3910006905 Medicaid

27/32

State: WV
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

038913700 Other

28/32

State: PA · Issuer: Keystone
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.

10026119900 Medicaid

29/32

State: NE
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

499596 Other

30/32

State: NJ · Issuer: Aetna
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.

7660804 Medicaid

31/32

State: NJ
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

SL0101 Medicaid

32/32

State: SC
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

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