Provider Demographics
NPI:1962429647
Name:TRI-STATE CARDIOLOGY
Entity type:Organization
Organization Name:TRI-STATE CARDIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:SEXTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-282-5054
Mailing Address - Street 1:2408 SUSANNAH ST
Mailing Address - Street 2:STE.1
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1728
Mailing Address - Country:US
Mailing Address - Phone:423-282-5054
Mailing Address - Fax:423-262-0220
Practice Address - Street 1:2408 SUSANNAH ST
Practice Address - Street 2:STE.1
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1728
Practice Address - Country:US
Practice Address - Phone:423-282-5054
Practice Address - Fax:423-262-0220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4058472OtherBCBS
VAC08273Medicare ID - Type UnspecifiedTRAILBLAZER MEDICARE
TN4058472OtherBCBS
TN3373123Medicare ID - Type UnspecifiedCIGNA MEDICARE