Provider Demographics
NPI:1902181134
Name:TRINITAS REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:TRINITAS REGIONAL MEDICAL CENTER
Other - Org Name:TRINITAS REGIONAL MEDICAL CENTER PHYSICIANS PRACTICE ACCTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:SAMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-298-0579
Mailing Address - Street 1:67 WALNUT AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-1640
Mailing Address - Country:US
Mailing Address - Phone:732-815-9872
Mailing Address - Fax:732-388-1330
Practice Address - Street 1:67 WALNUT AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:CLARK
Practice Address - State:NJ
Practice Address - Zip Code:07066-1640
Practice Address - Country:US
Practice Address - Phone:732-815-9872
Practice Address - Fax:732-388-1330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB71509207QS0010X
NJMB53933207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty