1396076881 NPI number — TRI-STATE MEDICAL GROUP, INC

Table of content: (NPI 1396076881)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396076881 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:
Provider Other Organization Name Type Code:
6
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:
1396076881
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/22/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
918 3RD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEAVER FALLS
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15010-4613
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-773-8895
Provider Business Mailing Address Fax Number:
724-770-7945

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
918 3RD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEAVER FALLS
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15010-4613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-773-8895
Provider Business Practice Location Address Fax Number:
724-770-7945
Provider Enumeration Date:
01/22/2010

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 , with the licence number:  MD437163 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

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




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