Provider Demographics
NPI:1306108618
Name:TRI-STATE ADVANCED PAIN MANAGEMENT
Entity type:Organization
Organization Name:TRI-STATE ADVANCED PAIN MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUK
Authorized Official - Middle Name:KI
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-684-5679
Mailing Address - Street 1:3332 VILLA PT
Mailing Address - Street 2:SUITE 104
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-7818
Mailing Address - Country:US
Mailing Address - Phone:270-684-5679
Mailing Address - Fax:270-684-5753
Practice Address - Street 1:444 S MAIN ST
Practice Address - Street 2:SUITE 133
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-2846
Practice Address - Country:US
Practice Address - Phone:270-825-4732
Practice Address - Fax:270-825-4733
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRI-STATE ADVANCED PAIN MANAGEMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-12
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY17728208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64177280Medicaid
KY64177280Medicaid