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General NPI Number Information
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NPI Number | 1780126664
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Entity Type | Organization
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Legal Business Name | TRINITY HEALTH SOUTH PLLC
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Dates
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Enumeration Date | 11/09/2016
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Last Update Date | 11/09/2016
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Provider Practice Location Address
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Address Line | 475 W TOWN PL SUITE 105
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City | ST AUGUSTINE
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State | FL
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Zip | 32092-3648
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Country | US
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Telephone | 904-806-4579
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Fax | 904-863-5566
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Provider Business Mailing Address
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Address Line | 110 CALLE NORTE
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City | ST AUGUSTINE
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State | FL
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Zip | 32092
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Country | US
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Telephone | 904-806-4579
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Fax | 904-863-5566
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Authorized Official
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Title or Position | CREDENTIALING COORDINATOR
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Name | WENDY C LU
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Credential |
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Telephone | 904-221-2535
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | ME104865
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License Number State | FL
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