Healthcare Provider Details

I. General information

NPI: 1225272198
Provider Name (Legal Business Name): TRINITY COLON AND RECTAL SURGERY CLINIC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2009
Last Update Date: 04/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8067 WEST VIRGINIA DRIVE
DALLAS TX
75237
US

IV. Provider business mailing address

8067 WEST VIRGINIA DRIVE
DALLAS TX
75237
US

V. Phone/Fax

Practice location:
  • Phone: 972-709-9300
  • Fax: 972-709-9307
Mailing address:
  • Phone: 972-709-9300
  • Fax: 972-709-9307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberN2543
License Number StateTX

VIII. Authorized Official

Name: DR. PAUL SAMUEL HACKETT
Title or Position: PRESIDENT
Credential: M.D.
Phone: 937-422-3186