Basic Information
| Provider Information | |||||||||
| NPI: | 1275705048 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRI-STATE PAIN MANAGEMENT SERVICE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7655 5 MILE RD STE 117 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452304326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136247525 | ||||||||
| FaxNumber: | 5136240578 | ||||||||
| Practice Location | |||||||||
| Address1: | 4415 AICHOLTZ RD | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452451506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593417246 | ||||||||
| FaxNumber: | 8593417867 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2008 | ||||||||
| LastUpdateDate: | 03/24/2020 | ||||||||
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| AuthorizedOfficialLastName: | ASHLEY | ||||||||
| AuthorizedOfficialFirstName: | JEWELL | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5136247525 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 208VP0014X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200529320A | 05 | IN | MEDICAID | 284941995017 | 01 | MEDICAL MUTUAL | OTHER | 5124498 | 01 | CIGNA | OTHER | 65944233 | 05 | KY | MEDICAID | 728014 | 01 | BUCKEYE | OTHER | 610168000 | 01 | FEDERAL WORKERS COMP | OTHER | 2044773 | 05 | OH | MEDICAID |