Provider Demographics
NPI:1811048085
Name:EL PASO PRIMARY HEALTHCARE PHYSICIAN
Entity type:Organization
Organization Name:EL PASO PRIMARY HEALTHCARE PHYSICIAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:TRILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-855-7900
Mailing Address - Street 1:1418 GEORGE DIETER DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-7601
Mailing Address - Country:US
Mailing Address - Phone:915-855-7900
Mailing Address - Fax:915-855-7755
Practice Address - Street 1:1418 GEORGE DIETER DR
Practice Address - Street 2:SUITE B
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-7601
Practice Address - Country:US
Practice Address - Phone:915-855-7900
Practice Address - Fax:915-855-7755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5234207Q00000X
TXJ2933207Q00000X
TXE5012207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========OtherTAX ID#
TX00679ZMedicare UPIN