Provider Demographics
NPI:1609020031
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:PO BOX 678234
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-8234
Mailing Address - Country:US
Mailing Address - Phone:817-886-8730
Mailing Address - Fax:817-866-8376
Practice Address - Street 1:800 W MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4611
Practice Address - Country:US
Practice Address - Phone:817-886-8730
Practice Address - Fax:817-866-8376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-12
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0A3258OtherMEDICARE PTAN