Provider Demographics
NPI:1194959452
Name:TRI STATE FAMILY MEDICAL CENTER, LLC
Entity type:Organization
Organization Name:TRI STATE FAMILY MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:GAUZE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-638-3131
Mailing Address - Street 1:2583 HIGHWAY 644 STE 1
Mailing Address - Street 2:
Mailing Address - City:LOUISA
Mailing Address - State:KY
Mailing Address - Zip Code:41230-9436
Mailing Address - Country:US
Mailing Address - Phone:606-638-3131
Mailing Address - Fax:606-638-3139
Practice Address - Street 1:2583 HIGHWAY 644 STE 1
Practice Address - Street 2:
Practice Address - City:LOUISA
Practice Address - State:KY
Practice Address - Zip Code:41230-9436
Practice Address - Country:US
Practice Address - Phone:606-638-3131
Practice Address - Fax:606-638-3139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-14
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY25469207Q00000X, 261QP2300X
25469261QU0200X
KY3007167363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty