Provider Demographics
NPI:1144760364
Name:HEBRON PHYSICAL MEDICINE PC
Entity Type:Organization
Organization Name:HEBRON PHYSICAL MEDICINE PC
Other - Org Name:TRINITY INTEGRATED MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:PECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-478-5538
Mailing Address - Street 1:1629 W HEBRON PKWY
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-6334
Mailing Address - Country:US
Mailing Address - Phone:972-478-5538
Mailing Address - Fax:972-820-7177
Practice Address - Street 1:1629 W HEBRON PKWY
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-6334
Practice Address - Country:US
Practice Address - Phone:972-478-5538
Practice Address - Fax:972-820-7177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-07
Last Update Date:2022-11-16
Deactivation Date:2017-03-07
Deactivation Code:
Reactivation Date:2017-03-07
Provider Licenses
StateLicense IDTaxonomies
TX7350111NR0400X
2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX609240OtherMEDICARE NUMBER