Provider Demographics
NPI:1922093061
Name:TROPHY CLUB FAMILY MEDICINE PA
Entity Type:Organization
Organization Name:TROPHY CLUB FAMILY MEDICINE PA
Other - Org Name:TROPHY CLUB FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAINEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-430-9111
Mailing Address - Street 1:301 TROPHY LAKE DR
Mailing Address - Street 2:#136
Mailing Address - City:TROPHY CLUB
Mailing Address - State:TX
Mailing Address - Zip Code:76262-5238
Mailing Address - Country:US
Mailing Address - Phone:817-430-9111
Mailing Address - Fax:817-430-8911
Practice Address - Street 1:301 TROPHY LAKE DR
Practice Address - Street 2:#136
Practice Address - City:TROPHY CLUB
Practice Address - State:TX
Practice Address - Zip Code:76262-5238
Practice Address - Country:US
Practice Address - Phone:817-430-9111
Practice Address - Fax:817-430-8911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-14
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0008JQOtherBLUE CROSS BLUE SHIELD
TX148222601Medicaid
TX148222601Medicaid