Provider Demographics
NPI:1255392924
Name:TRINITY MEDICAL CLINIC PA
Entity type:Organization
Organization Name:TRINITY MEDICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MERCELY
Authorized Official - Middle Name:RANI
Authorized Official - Last Name:DEVABAVUS MD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-666-5665
Mailing Address - Street 1:PO BOX 6117
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34611-6117
Mailing Address - Country:US
Mailing Address - Phone:352-666-5665
Mailing Address - Fax:352-666-5122
Practice Address - Street 1:10425 SPRING HILL DR
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34608-5043
Practice Address - Country:US
Practice Address - Phone:352-666-5665
Practice Address - Fax:352-666-5122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-31
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78188207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL257212500Medicaid
FLAL715Medicare PIN