Provider Demographics
NPI:1851498364
Name:TRI-STATE PULMONARY ASSOC PSC
Entity type:Organization
Organization Name:TRI-STATE PULMONARY ASSOC PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:R
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-329-1185
Mailing Address - Street 1:PO BOX 1380
Mailing Address - Street 2:613 23RD STREED MEDICAL PLAZA B SUITE G30
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-1380
Mailing Address - Country:US
Mailing Address - Phone:606-329-1185
Mailing Address - Fax:606-324-0585
Practice Address - Street 1:613 23RD ST
Practice Address - Street 2:MEDICAL PLAZA B SUITE G30
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2878
Practice Address - Country:US
Practice Address - Phone:606-329-1185
Practice Address - Fax:606-324-0585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-19
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY2588632OtherOMA
KY65940272Medicaid
KY0320OtherANTHEM
KY0320OtherANTHEM