1649217910 NPI number — TRI-STATE VASCULAR GROUP, PSC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649217910 NPI number — TRI-STATE VASCULAR GROUP, PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRI-STATE VASCULAR GROUP, PSC
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:
1649217910
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 149
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ASHLAND
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41105-0149
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-326-1675
Provider Business Mailing Address Fax Number:
606-326-1436

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2301 LEXINGTON AVE
Provider Second Line Business Practice Location Address:
SUITE 230
Provider Business Practice Location Address City Name:
ASHLAND
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41101-2873
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-326-1675
Provider Business Practice Location Address Fax Number:
606-326-1436
Provider Enumeration Date:
06/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ABUL-KHOUDOUD
Authorized Official First Name:
OMRAN
Authorized Official Middle Name:
RIAD
Authorized Official Title or Position:
PRESIDENT/VASCULAR SURGEON
Authorized Official Telephone Number:
606-326-1675

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  40007 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000484792 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7499265 . This is a "AETNA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 65945495 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2645436 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: DF0183 . This is a "MEDICARE RR" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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