Provider Demographics
NPI:1396076881
Name:TRI-STATE MEDICAL GROUP, INC
Entity type:Organization
Organization Name:TRI-STATE MEDICAL GROUP, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:NORMAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:MITRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-773-4776
Mailing Address - Street 1:918 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVER FALLS
Mailing Address - State:PA
Mailing Address - Zip Code:15010-4613
Mailing Address - Country:US
Mailing Address - Phone:724-773-8895
Mailing Address - Fax:724-770-7945
Practice Address - Street 1:918 3RD AVE
Practice Address - Street 2:
Practice Address - City:BEAVER FALLS
Practice Address - State:PA
Practice Address - Zip Code:15010-4613
Practice Address - Country:US
Practice Address - Phone:724-773-8895
Practice Address - Fax:724-770-7945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-22
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD437163207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015654460023Medicaid
PA0015654460023Medicaid