Provider Demographics
NPI:1508214222
Name:TRINITY DIAGNOSTIC CLINIC, P.A
Entity Type:Organization
Organization Name:TRINITY DIAGNOSTIC CLINIC, P.A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KOSURI
Authorized Official - Middle Name:B
Authorized Official - Last Name:RAJU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-905-2254
Mailing Address - Street 1:6324 SOUTHERN HILLS DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132
Mailing Address - Country:US
Mailing Address - Phone:817-905-2254
Mailing Address - Fax:
Practice Address - Street 1:6324 SOUTHERN HILLS DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4485
Practice Address - Country:US
Practice Address - Phone:817-905-2254
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-03
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG7866275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123216705Medicaid
00R31BMedicare PIN
TX123216705Medicaid