Basic Information
| Provider Information | |||||||||
| NPI: | 1215164488 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRI-STATE MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 DUTCH RIDGE ROAD C-4 | ||||||||
| Address2: | HERITAGE VALLEY BEAVER CREDENTIALING | ||||||||
| City: | BEAVER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 15009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7247734776 | ||||||||
| FaxNumber: | 7247734726 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 CHIPPEWA TOWN CTR. | ||||||||
| Address2: | HERITAGE VALLEY CONVENIENT CARE-BEAVER FALLS | ||||||||
| City: | BEAVER FALLS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 15010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7247742942 | ||||||||
| FaxNumber: | 7247745175 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2009 | ||||||||
| LastUpdateDate: | 06/18/2009 | ||||||||
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| AuthorizedOfficialLastName: | MITRY | ||||||||
| AuthorizedOfficialFirstName: | NORMAN | ||||||||
| AuthorizedOfficialMiddleName: | F. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 7247734776 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363AM0700X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0014950830029 | 05 | PA | MEDICAID | 1007289980010 | 05 | PA | MEDICAID | 0015654460023 | 05 | PA | MEDICAID |