1770594061 NPI number — TRI STATE NEPHROLOGY ASSOCIATES 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 1770594061 NPI number — TRI STATE NEPHROLOGY ASSOCIATES PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRI STATE NEPHROLOGY ASSOCIATES 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:
1770594061
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
432 16TH ST
Provider Second Line Business Mailing Address:
P.O.BOX 2468
Provider Business Mailing Address City Name:
ASHLAND
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41101-7693
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-329-9335
Provider Business Mailing Address Fax Number:
606-324-6383

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
432 16TH ST STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASHLAND
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41101-7693
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-329-9335
Provider Business Practice Location Address Fax Number:
606-324-6383
Provider Enumeration Date:
08/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HAMMONDS
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
N.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
606-329-9335

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 65918237 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0833263 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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