Provider Demographics
NPI:1487898383
Name:TRINITY PHYSICIANS GROUP SC
Entity type:Organization
Organization Name:TRINITY PHYSICIANS GROUP SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:LONGO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:630-830-8192
Mailing Address - Street 1:PO BOX 1509
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60121-1509
Mailing Address - Country:US
Mailing Address - Phone:224-238-4200
Mailing Address - Fax:847-214-9489
Practice Address - Street 1:590 COBBLESTONE LN
Practice Address - Street 2:
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-1562
Practice Address - Country:US
Practice Address - Phone:630-830-8192
Practice Address - Fax:630-830-8284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-23
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036115234207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036115234Medicaid
IL2234136OtherBCBS
ILIL2215Medicare PIN
IL036115234Medicaid