Provider Demographics
NPI:1891991238
Name:TRINITY FAMILY AND SPORTS MEDICINE PA
Entity Type:Organization
Organization Name:TRINITY FAMILY AND SPORTS MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:D
Authorized Official - Last Name:TIPPETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-376-3547
Mailing Address - Street 1:1807 SHORT BRANCH DRIVE
Mailing Address - Street 2:#102
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655
Mailing Address - Country:US
Mailing Address - Phone:727-376-3547
Mailing Address - Fax:866-439-9035
Practice Address - Street 1:1807 SHORT BRANCH DR
Practice Address - Street 2:#102
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-4415
Practice Address - Country:US
Practice Address - Phone:727-376-3547
Practice Address - Fax:866-439-9035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93868207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL279176500Medicaid
FL279176500Medicaid