Basic Information
| Provider Information | |||||||||
| NPI: | 1457416570 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRIMBLE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1825 MARTHA BERRY BLVD NW | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301651625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062955331 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3540 COBB PKWY NW | ||||||||
| Address2: | |||||||||
| City: | ACWORTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709743911 | ||||||||
| FaxNumber: | 7704050606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2006 | ||||||||
| LastUpdateDate: | 11/19/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 030231 | GA | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 000362403B | 05 | GA | MEDICAID | 000362403F | 05 | GA | MEDICAID | 000362403G | 05 | GA | MEDICAID |