Provider Demographics
NPI:1356391734
Name:TRINITY CLINIC
Entity type:Organization
Organization Name:TRINITY CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN CLINICSUPPORT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-510-1113
Mailing Address - Street 1:PO BOX 5500
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75712-5500
Mailing Address - Country:US
Mailing Address - Phone:903-324-6400
Mailing Address - Fax:
Practice Address - Street 1:910 E HOUSTON ST
Practice Address - Street 2:STE 530
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8366
Practice Address - Country:US
Practice Address - Phone:903-592-7393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRINITY CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-10
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X
TX208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138737511Medicaid
TX00T69UMedicare ID - Type Unspecified
TX138737511Medicaid