1013098904 NPI number — TRI-STATE PEDIATRICS

Table of content: (NPI 1013098904)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013098904 NPI number — TRI-STATE PEDIATRICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRI-STATE PEDIATRICS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013098904
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 SAINT CHRISTOPHER DR
Provider Second Line Business Mailing Address:
BUILDING 4 SUITE 101
Provider Business Mailing Address City Name:
ASHLAND
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41101-7090
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-836-0919
Provider Business Mailing Address Fax Number:
606-836-2847

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 SAINT CHRISTOPHER DR
Provider Second Line Business Practice Location Address:
BUILDING 4 SUITE 101
Provider Business Practice Location Address City Name:
ASHLAND
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41101-7090
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-836-0919
Provider Business Practice Location Address Fax Number:
606-836-2847
Provider Enumeration Date:
10/18/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SISLER
Authorized Official First Name:
MICHELLE
Authorized Official Middle Name:
ELIZABETH
Authorized Official Title or Position:
BILLING CLERK
Authorized Official Telephone Number:
606-836-0919

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  25781 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X , with the licence number: 02639 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 174400000X , with the licence number: 38597 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 64011059 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02639 . This is a "KY LICENSE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 38597 . This is a "KY LICENSE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 64066384 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2271429 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0665310 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 25781 . This is a "KY LICENSE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 64257819 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".