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General NPI Number Information
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NPI Number | 1508214222
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Entity Type | Organization
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Legal Business Name | TRINITY DIAGNOSTIC CLINIC, P.A
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Dates
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Enumeration Date | 06/03/2016
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Last Update Date | 06/03/2016
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Provider Practice Location Address
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Address Line | 6324 SOUTHERN HILLS DR
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City | FORT WORTH
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State | TX
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Zip | 76132-4485
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Country | US
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Telephone | 817-905-2254
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Fax |
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Provider Business Mailing Address
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Address Line | 6324 SOUTHERN HILLS DR
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City | FORT WORTH
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State | TX
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Zip | 76132
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Country | US
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Telephone | 817-905-2254
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | KOSURI B RAJU
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Credential | M.D.
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Telephone | 817-905-2254
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 275N00000X
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Taxonomy Name | Medicare Defined Swing Bed Hospital Unit
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License Number | G7866
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License Number State | TX
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