Provider Demographics
NPI:1215106323
Name:TRI-STATE PAIN INSTITUTE LLC
Entity type:Organization
Organization Name:TRI-STATE PAIN INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:A
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-833-1147
Mailing Address - Street 1:2374 VILLAGE COMMON DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-7201
Mailing Address - Country:US
Mailing Address - Phone:814-833-7246
Mailing Address - Fax:814-833-1147
Practice Address - Street 1:2374 VILLAGE COMMON DR
Practice Address - Street 2:SUITE 100
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-7201
Practice Address - Country:US
Practice Address - Phone:814-833-7246
Practice Address - Fax:814-833-1147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-22
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD045797L2081P2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0717424Medicaid
PA0012660260005Medicaid
PA273480OtherBLUE SHIELD
PA273480OtherBLUE SHIELD
PA125192Medicare PIN
PAC03670Medicare UPIN
PA090452Medicare PIN