Basic Information
| Provider Information | |||||||||
| NPI: | 1114094802 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRI-STATE CENTERS FOR SIGHT, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 631662 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452631662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8595817120 | ||||||||
| FaxNumber: | 8595817207 | ||||||||
| Practice Location | |||||||||
| Address1: | 2135 DANA AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452071313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132217788 | ||||||||
| FaxNumber: | 5134875223 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 03/30/2016 | ||||||||
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| AuthorizedOfficialLastName: | BARBERY | ||||||||
| AuthorizedOfficialFirstName: | JACKIE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8593442062 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 0188354 | 05 | OH | MEDICAID | 100002110 J | 05 | IN | MEDICAID |