Provider Demographics
NPI:1104317346
Name:TRI STATE COMMUNITY CLINIC, LLC
Entity type:Organization
Organization Name:TRI STATE COMMUNITY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:CHAD
Authorized Official - Last Name:PERKINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:888-492-8722
Mailing Address - Street 1:1033 E MT. PLEASANT RD., STE. D
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47725
Mailing Address - Country:US
Mailing Address - Phone:888-492-8722
Mailing Address - Fax:812-491-0333
Practice Address - Street 1:1033 E MT. PLEASANT RD., STE. D.
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47725
Practice Address - Country:US
Practice Address - Phone:888-492-8722
Practice Address - Fax:812-491-0333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty