MEDICARE: TRINITY CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1376593335
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRINITY CLINIC

Provider Business Mailing Address
First Line	:	PO BOX 5500
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75712-5500
Country	:	US
Telephone Number	:	903-324-6400
Fax Number	:

Provider Business Practice Location Address
First Line	:	1718 S HENDERSON BLVD
Second Line	:
City	:	KILGORE
State	:	TX
Zip	:	75662-3566
Country	:	US
Telephone Number	:	903-983-2110
Fax Number	:	903-986-9148

Authorized Official
Title or Position	:	PHYSICIAN CLINIC SUPPORT COORD
Name	:	MARY A HARRISON
Credential	:	CPC CMC
Telephone Number	:	903-510-1113

Provider Enumeration Date	:	05/11/2006
Last Update Date	:	06/03/2008

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Directions to “TRINITY CLINIC ” Practice Location

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