Basic Information
| Provider Information | |||||||||
| NPI: | 1487898383 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRINITY PHYSICIANS GROUP SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1509 | ||||||||
| Address2: | |||||||||
| City: | ELGIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601211509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2242384200 | ||||||||
| FaxNumber: | 8472149489 | ||||||||
| Practice Location | |||||||||
| Address1: | 590 COBBLESTONE LN | ||||||||
| Address2: | |||||||||
| City: | BUFFALO GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600891562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308308192 | ||||||||
| FaxNumber: | 6308308284 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2009 | ||||||||
| LastUpdateDate: | 01/07/2010 | ||||||||
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| AuthorizedOfficialLastName: | LONGO | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6308308192 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036115234 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036115234 | 05 | IL | MEDICAID | 2234136 | 01 | IL | BCBS | OTHER |