Basic Information
| Provider Information | |||||||||
| NPI: | 1205878931 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRI-STATE EMERGENCY PHYSICIANS PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 484 TEMPLE HILL RD | ||||||||
| Address2: | |||||||||
| City: | NEW WINDSOR | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125535529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8455653700 | ||||||||
| FaxNumber: | 8455653395 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PORT JERVIS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 127712253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8458587000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 09/23/2009 | ||||||||
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| AuthorizedOfficialLastName: | RUVO | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8455653700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01673803 | 05 | NY | MEDICAID | 7487703 | 01 | NY | UNYSIS | OTHER |