Provider Demographics
NPI:1043421894
Name:TRILLIUM MEDICAL GROUP OF VIRGINIA, INC.
Entity Type:Organization
Organization Name:TRILLIUM MEDICAL GROUP OF VIRGINIA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:L
Authorized Official - Last Name:COATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-403-5221
Mailing Address - Street 1:PO BOX 23788
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33623-3788
Mailing Address - Country:US
Mailing Address - Phone:800-750-8103
Mailing Address - Fax:866-788-0863
Practice Address - Street 1:301 FUGATE ST # B
Practice Address - Street 2:
Practice Address - City:DUFFIELD
Practice Address - State:VA
Practice Address - Zip Code:24244-9794
Practice Address - Country:US
Practice Address - Phone:800-750-8103
Practice Address - Fax:866-788-0863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA493870Medicare ID - Type UnspecifiedRURAL HEALTH