Provider Demographics
NPI:1598782401
Name:TRINITY FAMILY MEDICAL CENTER, PA
Entity Type:Organization
Organization Name:TRINITY FAMILY MEDICAL CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:352-483-4837
Mailing Address - Street 1:PO BOX 490
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32727-0490
Mailing Address - Country:US
Mailing Address - Phone:352-253-2511
Mailing Address - Fax:352-253-2522
Practice Address - Street 1:1707 MAYO DRIVE
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778
Practice Address - Country:US
Practice Address - Phone:352-253-2511
Practice Address - Fax:352-253-2522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL059170207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
I23068Medicare UPIN
FLK8279Medicare ID - Type Unspecified