Basic Information
| Provider Information | |||||||||
| NPI: | 1770699902 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRINITY MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TRINITY WORK FITNESS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 555 VALLEY VIEW DR | ||||||||
| Address2: | |||||||||
| City: | MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612656138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097649675 | ||||||||
| FaxNumber: | 3097643106 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 VALLEY VIEW DR | ||||||||
| Address2: | |||||||||
| City: | MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612656138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097649675 | ||||||||
| FaxNumber: | 3097643106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EVERSON | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE LEAD/COMPLIANCE COO | ||||||||
| AuthorizedOfficialTelephone: | 5637425914 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.