Provider Demographics
NPI:1215281761
Name:TRINITY HEALTHCARE PC
Entity type:Organization
Organization Name:TRINITY HEALTHCARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INCORPORATOR/SHAREHOLDER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ABRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-619-1329
Mailing Address - Street 1:2740 N MAYFAIR AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-5084
Mailing Address - Country:US
Mailing Address - Phone:417-521-3925
Mailing Address - Fax:
Practice Address - Street 1:2740 N MAYFAIR AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-5084
Practice Address - Country:US
Practice Address - Phone:417-521-3925
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-06
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD115778207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1760595136OtherPERSONAL NPI
1760595136OtherPERSONAL NPI