Provider Demographics
NPI:1306996459
Name:TRISOURCE GROUP INC
Entity type:Organization
Organization Name:TRISOURCE GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROSALYN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-923-0250
Mailing Address - Street 1:7710 HARPER
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48213
Mailing Address - Country:US
Mailing Address - Phone:313-923-0250
Mailing Address - Fax:313-923-0205
Practice Address - Street 1:7710 HARPER
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213
Practice Address - Country:US
Practice Address - Phone:313-923-0250
Practice Address - Fax:313-923-0205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies