Provider Demographics
NPI:1992793442
Name:TRISHARD P.C.
Entity type:Organization
Organization Name:TRISHARD P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:PANTELLI
Authorized Official - Suffix:
Authorized Official - Credentials:MA,CCC-SLP
Authorized Official - Phone:248-568-3563
Mailing Address - Street 1:2117 E 11 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-3553
Mailing Address - Country:US
Mailing Address - Phone:586-573-4684
Mailing Address - Fax:586-573-2575
Practice Address - Street 1:2117 E 11 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-3553
Practice Address - Country:US
Practice Address - Phone:586-573-4684
Practice Address - Fax:586-573-2575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-10
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI261QP2000X, 261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI30628OtherBLUE CROSS BLUE SHIELD
MI30628OtherBLUE CARE NETWORK
MI30628OtherBLUE CROSS BLUE SHIELD