Healthcare Provider Details

I. General information

NPI: 1356391734
Provider Name (Legal Business Name): TRINITY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 09/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 E HOUSTON ST STE 530
TYLER TX
75702-8366
US

IV. Provider business mailing address

PO BOX 5500
TYLER TX
75712-5500
US

V. Phone/Fax

Practice location:
  • Phone: 903-592-7393
  • Fax:
Mailing address:
  • Phone: 903-324-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number StateTX

VIII. Authorized Official

Name: MARY ANN HARRISON
Title or Position: PHYSICIAN CLINICSUPPORT COORDINATOR
Credential:
Phone: 903-510-1113