Organization
TRINITY DIAGNOSTIC CLINIC, P.A
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KOSURI B RAJU M.D. (PRESIDENT)
(817) 905-2254
Entity
Organization
Contact information
Practice address
6324 SOUTHERN HILLS DR, FORT WORTH, TX 76132-4485
(817) 905-2254
Mailing address
6324 SOUTHERN HILLS DR, FORT WORTH, TX 76132
(817) 905-2254
Taxonomy
Speciality
Code
Description
License number
State
275N00000X
Medicare Defined Swing Bed Hospital Unit
Primary
G7866
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
123216705
—
TX
Enumeration date
06/03/2016
Last updated
06/03/2016
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