Provider Demographics
NPI:1609247311
Name:TRINITY PEDIATRIC MEDICINE OF FAYETTEVILLE
Entity Type:Organization
Organization Name:TRINITY PEDIATRIC MEDICINE OF FAYETTEVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-517-8368
Mailing Address - Street 1:719 LANIER AVE W STE A2
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-7634
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3695 CASCADE RD SW STE V
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-2146
Practice Address - Country:US
Practice Address - Phone:404-696-6595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-08
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty