1770565954 NPI number — TRI-STATE PAIN MANAGEMENT SERVICE INC

Table of content: (NPI 1770565954)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770565954 NPI number — TRI-STATE PAIN MANAGEMENT SERVICE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRI-STATE PAIN MANAGEMENT SERVICE 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:
1770565954
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7655 5 MILE RD STE 117
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45230-4326
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-624-7525
Provider Business Mailing Address Fax Number:
513-624-0578

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7655 FIVE MILE RD
Provider Second Line Business Practice Location Address:
STE 117
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-341-7246
Provider Business Practice Location Address Fax Number:
513-624-0578
Provider Enumeration Date:
11/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ASHLEY
Authorized Official First Name:
JEWELL
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
513-624-7525

Provider Taxonomy Codes

  • Taxonomy code: 208VP0014X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 728014 . This is a "BUCKEYE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 65944233 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2044773 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000388145 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 200529320A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5124498 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".




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