Healthcare Provider Details

I. General information

NPI: 1891991238
Provider Name (Legal Business Name): TRINITY FAMILY AND SPORTS MEDICINE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2007
Last Update Date: 07/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1807 SHORT BRANCH DR #102
TRINITY FL
34655-4415
US

IV. Provider business mailing address

1807 SHORT BRANCH DRIVE #102
TRINITY FL
34655
US

V. Phone/Fax

Practice location:
  • Phone: 727-376-3547
  • Fax: 866-439-9035
Mailing address:
  • Phone: 727-376-3547
  • Fax: 866-439-9035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberME93868
License Number StateFL

VIII. Authorized Official

Name: DR. JESSE D TIPPETT
Title or Position: OWNER
Credential: MD
Phone: 727-376-3547