Provider Demographics
NPI:1033163829
Name:TRINITY MEDICAL CENTER
Entity Type:Organization
Organization Name:TRINITY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR SUPPORT SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:PROVATEARE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-779-2022
Mailing Address - Street 1:4600 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6106
Mailing Address - Country:US
Mailing Address - Phone:309-779-2032
Mailing Address - Fax:
Practice Address - Street 1:2701 17TH ST
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-5351
Practice Address - Country:US
Practice Address - Phone:309-779-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No273R00000XHospital UnitsPsychiatric UnitGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0276170Medicaid
IA0219253Medicaid
04049OtherBCWELLMARK ENRICH GR
ILCB8516OtherRR MEDICARE
ILCB8524OtherRR MEDICARE
ILCB8530OtherRR MEDICARE
ILCB8166OtherRR MEDICARE
8115303OtherBCILLINOIS RYC
ILCK0834OtherRR MEDICARE
99817OtherBCWELLMARK GROUP
99817OtherBCWELLMARK GROUP
ILCB8530OtherRR MEDICARE
ILCB8524OtherRR MEDICARE