Provider Demographics
NPI:1386786796
Name:TRI-STATE ALLERGY, INC
Entity type:Organization
Organization Name:TRI-STATE ALLERGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:C
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-529-6100
Mailing Address - Street 1:1001 20TH ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25703-2019
Mailing Address - Country:US
Mailing Address - Phone:304-529-6100
Mailing Address - Fax:304-529-0229
Practice Address - Street 1:2301 LEXINGTON AVE STE 105
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2807
Practice Address - Country:US
Practice Address - Phone:304-529-6100
Practice Address - Fax:304-529-0229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64698772Medicaid
KY64694763Medicaid
KY65930083Medicaid
WVF39127Medicare UPIN
KY0518402Medicare ID - Type UnspecifiedLYNCH PERSONAL
KY5184Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
KY0518401Medicare ID - Type UnspecifiedWILSON PERSONAL
KY65930083Medicaid