Healthcare Provider Details

I. General information

NPI: 1316080559
Provider Name (Legal Business Name): TRINA J BLYTHE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 02/13/2023
Certification Date: 02/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 PROGRESS POINT PKWY STE 100
O FALLON MO
63368-2207
US

IV. Provider business mailing address

20 PROGRESS POINT PKWY STE 100
O FALLON MO
63368-2207
US

V. Phone/Fax

Practice location:
  • Phone: 636-344-2213
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number119707
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: