Provider Demographics
NPI:1023136116
Name:TRITON SURGICAL ASSOCIATES PA
Entity type:Organization
Organization Name:TRITON SURGICAL ASSOCIATES PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:K
Authorized Official - Last Name:LYNCH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:432-580-7373
Mailing Address - Street 1:408 N HANCOCK AVENUE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-5140
Mailing Address - Country:US
Mailing Address - Phone:432-580-7373
Mailing Address - Fax:432-580-3275
Practice Address - Street 1:408 N HANCOCK AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5140
Practice Address - Country:US
Practice Address - Phone:432-580-7373
Practice Address - Fax:432-580-3275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3317208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX096986702Medicaid
TX096986702Medicaid