Provider Demographics
NPI:1366680217
Name:TRINITY CLINIC
Entity Type:Organization
Organization Name:TRINITY CLINIC
Other - Org Name:TRINITY CLINIC NEUROSURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER ENROLLMENT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:CPC CMC
Authorized Official - Phone:903-510-1113
Mailing Address - Street 1:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6400
Mailing Address - Fax:
Practice Address - Street 1:910 E HOUSTON ST
Practice Address - Street 2:STE 330
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8368
Practice Address - Country:US
Practice Address - Phone:903-525-7995
Practice Address - Fax:903-525-7929
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRINITY CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-30
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1091520021Medicare NSC