Provider Demographics
NPI:1366681702
Name:PRO PHYSICIANS CLINIC PA
Entity Type:Organization
Organization Name:PRO PHYSICIANS CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:D
Authorized Official - Last Name:TRYGGESTAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-886-8730
Mailing Address - Street 1:600 E JOHN CARPENTER FWY
Mailing Address - Street 2:SUITE 130
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75062-3990
Mailing Address - Country:US
Mailing Address - Phone:817-886-8730
Mailing Address - Fax:
Practice Address - Street 1:2800 E HIGHWAY 114
Practice Address - Street 2:SUITE 100
Practice Address - City:TROPHY CLUB
Practice Address - State:TX
Practice Address - Zip Code:76262-5304
Practice Address - Country:US
Practice Address - Phone:817-886-8730
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRO PHYSICIANS CLINIC PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-09
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty