1811935067 NPI number — TRI-STATE GASTROENTEROLOGY P.C.

Table of content: (NPI 1811935067)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811935067 NPI number — TRI-STATE GASTROENTEROLOGY P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRI-STATE GASTROENTEROLOGY P.C.
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:
1811935067
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5068
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANSVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47716-5068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-842-2701
Provider Business Mailing Address Fax Number:
812-842-2717

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4133 GATEWAY BLVD
Provider Second Line Business Practice Location Address:
SUITE 290
Provider Business Practice Location Address City Name:
NEWBURGH
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47630-7953
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-842-2701
Provider Business Practice Location Address Fax Number:
812-842-2717
Provider Enumeration Date:
06/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCCORD
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
812-842-2701

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  01038295 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200073540A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100180010A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100002411 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000042589 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 400746743 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 64871676 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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