1902073554 NPI number — TRI-STATE BEHAVIORAL HEALTH LLC

Table of content: (NPI 1902073554)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902073554 NPI number — TRI-STATE BEHAVIORAL HEALTH LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRI-STATE BEHAVIORAL HEALTH LLC
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:
1902073554
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1900 WATERS RIDGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWBURGH
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47630-8084
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-962-2353
Provider Business Mailing Address Fax Number:
812-962-0915

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1116 MILLIS AVE
Provider Second Line Business Practice Location Address:
ST. MARY'S WARRICK
Provider Business Practice Location Address City Name:
BOONVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-962-2353
Provider Business Practice Location Address Fax Number:
812-962-0915
Provider Enumeration Date:
05/13/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ASHRAF
Authorized Official First Name:
ANJUM
Authorized Official Middle Name:
SHEHZAD
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
812-962-2353

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  01048619A , 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: 200478750 A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 234630 . This is a "MEDICARE - ID" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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