Provider Demographics
NPI:1083034839
Name:TROPHY CLUB PEDIATRICS PA
Entity Type:Organization
Organization Name:TROPHY CLUB PEDIATRICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:O
Authorized Official - Last Name:ONYEAMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-574-4199
Mailing Address - Street 1:625 PARKVIEW DRIVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:TROPHY CLUB
Mailing Address - State:TX
Mailing Address - Zip Code:76262-3479
Mailing Address - Country:US
Mailing Address - Phone:817-400-1572
Mailing Address - Fax:
Practice Address - Street 1:2811 MONA VALE RD
Practice Address - Street 2:
Practice Address - City:TROPHY CLUB
Practice Address - State:TX
Practice Address - Zip Code:76262-3479
Practice Address - Country:US
Practice Address - Phone:708-574-4199
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-21
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care