Provider Demographics
NPI:1740534262
Name:TRINITY MEDICAL GROUP
Entity type:Organization
Organization Name:TRINITY MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:STANWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-401-8516
Mailing Address - Street 1:550 POPE AVE
Mailing Address - Street 2:POPE MEDICAL PLAZA
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881
Mailing Address - Country:US
Mailing Address - Phone:863-293-2144
Mailing Address - Fax:863-293-3732
Practice Address - Street 1:550 POPE AVE
Practice Address - Street 2:POPE MEDICAL PLAZA
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881
Practice Address - Country:US
Practice Address - Phone:863-293-2144
Practice Address - Fax:863-293-3732
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRQ, INC DBA PEDIATRIC PARTNERS OF WH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-06
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty