Provider Demographics
NPI:1467997262
Name:TRINITY PEDIATRICS LLC
Entity Type:Organization
Organization Name:TRINITY PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROETZER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-228-0439
Mailing Address - Street 1:23 AUTUMNVIEW RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-1601
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3055 SOUTHWESTERN BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1231
Practice Address - Country:US
Practice Address - Phone:716-228-0439
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY206060-1261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBD5368104OtherDEA