Provider Demographics
NPI:1730193657
Name:TRINITY MEDICAL CENTER, P.C.
Entity type:Organization
Organization Name:TRINITY MEDICAL CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:PETROS
Authorized Official - Last Name:AL-MATCHY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-275-0065
Mailing Address - Street 1:37300 DEQUINDRE RD
Mailing Address - Street 2:STE 120
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-3591
Mailing Address - Country:US
Mailing Address - Phone:586-275-0065
Mailing Address - Fax:586-275-0066
Practice Address - Street 1:37300 DEQUINDRE RD
Practice Address - Street 2:SUITE 120
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-3591
Practice Address - Country:US
Practice Address - Phone:586-275-0065
Practice Address - Fax:586-275-0066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070663207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301070663OtherSTATE LICENSE
MI700E027480OtherBCBS
MI4889519 10Medicaid
MIH45291Medicare UPIN
MI0P34310Medicare PIN