1508001538 NPI number — TRI-STATE MEDICAL GROUP, INC

Table of content: (NPI 1508001538)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508001538 NPI number — TRI-STATE MEDICAL GROUP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRI-STATE MEDICAL GROUP, INC
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:
CONVENIENT CARE CENTER-BEAVER
Provider Other Organization Name Type Code:
3
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:
1508001538
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
274 3RD ST
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
BEAVER
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15009-2333
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-774-2942
Provider Business Mailing Address Fax Number:
724-774-2942

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
274 3RD ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
BEAVER
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15009-2333
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-774-2942
Provider Business Practice Location Address Fax Number:
724-774-2942
Provider Enumeration Date:
12/04/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MITRY
Authorized Official First Name:
NORMAN
Authorized Official Middle Name:
F.
Authorized Official Title or Position:
PRESIDENT & CEO
Authorized Official Telephone Number:
724-773-4776

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0015654460023 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0015486320010 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0202677 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1007289980010 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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