Provider Demographics
NPI:1265579254
Name:BIVALACQUA, TRINITY J (MD PHD)
Entity type:Individual
Prefix:
First Name:TRINITY
Middle Name:J
Last Name:BIVALACQUA
Suffix:
Gender:M
Credentials:MD PHD
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3400 CIVIC CENTER BLVD
Mailing Address - Street 2:WEST PAVILION 3RD FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-5127
Mailing Address - Country:US
Mailing Address - Phone:215-662-2891
Mailing Address - Fax:215-662-6734
Practice Address - Street 1:3400 CIVIC CENTER BLVD
Practice Address - Street 2:WEST PAVILION 3RD FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-5127
Practice Address - Country:US
Practice Address - Phone:215-662-2891
Practice Address - Fax:215-662-6734
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD475725208800000X
MDD69964208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD028033000Medicaid
MDAJ4147357Medicare ID - Type Unspecified
MD176054ZAM2Medicare PIN