Provider Demographics
NPI:1386730331
Name:TRI-STATE RADIOLOGY, PC
Entity type:Organization
Organization Name:TRI-STATE RADIOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:NICKOLAS
Authorized Official - Last Name:PAPPAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-723-5581
Mailing Address - Street 1:PO BOX 3206
Mailing Address - Street 2:
Mailing Address - City:LAVALE
Mailing Address - State:MD
Mailing Address - Zip Code:21504-3206
Mailing Address - Country:US
Mailing Address - Phone:301-723-5581
Mailing Address - Fax:301-723-5745
Practice Address - Street 1:900 SETON DR
Practice Address - Street 2:DEPARTMENT OF RADIOLOGY
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-1854
Practice Address - Country:US
Practice Address - Phone:301-723-5581
Practice Address - Fax:301-723-5745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0010353000Medicaid
MDCD6376Medicare PIN
WV0010353000Medicaid