Provider Demographics
NPI:1225272198
Name:TRINITY COLON AND RECTAL SURGERY CLINIC, PA
Entity Type:Organization
Organization Name:TRINITY COLON AND RECTAL SURGERY CLINIC, PA
Other - Org Name:TRINITY COLONRECTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:SAMUEL
Authorized Official - Last Name:HACKETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-422-3186
Mailing Address - Street 1:8067 WEST VIRGINIA DRIVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75237
Mailing Address - Country:US
Mailing Address - Phone:972-709-9300
Mailing Address - Fax:972-709-9307
Practice Address - Street 1:8067 WEST VIRGINIA DRIVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237
Practice Address - Country:US
Practice Address - Phone:972-709-9300
Practice Address - Fax:972-709-9307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-23
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN2543208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty