Basic Information
| Provider Information | |||||||||
| NPI: | 1396267886 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRI-STATE PHYSIATRY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1160 VAN VOORHIS RD | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265053437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045981100 | ||||||||
| FaxNumber: | 3045981103 | ||||||||
| Practice Location | |||||||||
| Address1: | 1160 VAN VOORHIS RD | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265053437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045981100 | ||||||||
| FaxNumber: | 3045981103 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | GIBBS-MCELVYQ | ||||||||
| AuthorizedOfficialFirstName: | SHELANA | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7249234028 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 208100000X | WV | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.