1275631459 NPI number — TRINITY PAIN MEDICINE ASSOCIATES PA

Table of content: (NPI 1275631459)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275631459 NPI number — TRINITY PAIN MEDICINE ASSOCIATES PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRINITY PAIN MEDICINE ASSOCIATES PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275631459
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/09/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9290
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76147-2290
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-332-3664
Provider Business Mailing Address Fax Number:
817-336-6440

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1401 HENDERSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76102-6026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-332-3664
Provider Business Practice Location Address Fax Number:
817-336-6440
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CLASSEN
Authorized Official First Name:
ASHLEY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
817-332-3664

Provider Taxonomy Codes

  • Taxonomy code: 208VP0014X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0040CG . This is a "GROUP NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 079577501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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