Basic Information
| Provider Information | |||||||||
| NPI: | 1194182188 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRI COUNTY MEDICAL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7611 PERSHING BLVD | ||||||||
| Address2: | |||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531424317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626973668 | ||||||||
| FaxNumber: | 2626973500 | ||||||||
| Practice Location | |||||||||
| Address1: | 4310 W CRYSTAL LAKE RD | ||||||||
| Address2: | SUITE F | ||||||||
| City: | MCHENRY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600504214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153633223 | ||||||||
| FaxNumber: | 8153633240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2016 | ||||||||
| LastUpdateDate: | 01/21/2016 | ||||||||
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| AuthorizedOfficialLastName: | KHAN | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2626973668 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | T059603 | WI | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.