Provider Demographics
NPI:1144273830
Name:TRINIDAD MEDICAL ASSOCIATES , LLC
Entity type:Organization
Organization Name:TRINIDAD MEDICAL ASSOCIATES , LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLISLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-845-0627
Mailing Address - Street 1:400 BENEDICTA AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:TRINIDAD
Mailing Address - State:CO
Mailing Address - Zip Code:81082-2089
Mailing Address - Country:US
Mailing Address - Phone:719-845-0627
Mailing Address - Fax:719-845-0663
Practice Address - Street 1:400 BENEDICTA AVE
Practice Address - Street 2:SUITE E
Practice Address - City:TRINIDAD
Practice Address - State:CO
Practice Address - Zip Code:81082-2089
Practice Address - Country:US
Practice Address - Phone:719-845-0627
Practice Address - Fax:719-845-0663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO05638937Medicaid
CO063850Medicare ID - Type Unspecified