Provider Demographics
NPI:1568852754
Name:TRI-STATE PSYCHIATRY AND ADDICTION MEDICINE, PLLC
Entity type:Organization
Organization Name:TRI-STATE PSYCHIATRY AND ADDICTION MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:AHMED
Authorized Official - Middle Name:
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-519-6164
Mailing Address - Street 1:951 EASTGATE LOOP
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37411-4015
Mailing Address - Country:US
Mailing Address - Phone:423-296-6451
Mailing Address - Fax:423-296-6515
Practice Address - Street 1:951 EASTGATE LOOP
Practice Address - Street 2:SUITE 100
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37411-4015
Practice Address - Country:US
Practice Address - Phone:423-296-6451
Practice Address - Fax:423-296-6515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-27
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health