Provider Demographics
NPI:1396410882
Name:TRINITY PEDIATRIC MEDICINE OF COLLEGE PARK, LLC
Entity Type:Organization
Organization Name:TRINITY PEDIATRIC MEDICINE OF COLLEGE PARK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:CARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-472-3734
Mailing Address - Street 1:6524 OLD NATIONAL HWY
Mailing Address - Street 2:BLDG. B, STE 102
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30349
Mailing Address - Country:US
Mailing Address - Phone:678-472-3734
Mailing Address - Fax:
Practice Address - Street 1:6524 OLD NATIONAL HWY
Practice Address - Street 2:BLDG. B, STE 102
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30349
Practice Address - Country:US
Practice Address - Phone:678-472-3734
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1407950876OtherPEDIATRIC MEDICINE