Basic Information
| Provider Information | |||||||||
| NPI: | 1407028269 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRI-STATE PAIN MANAGEMENT SERVICE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | L-6067 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452706067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593417246 | ||||||||
| FaxNumber: | 8593417867 | ||||||||
| Practice Location | |||||||||
| Address1: | 7500 STATE RD | ||||||||
| Address2: | MERCY ANDERSON HOSPITAL | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452552439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593417246 | ||||||||
| FaxNumber: | 8593417867 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2008 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | ATLURI | ||||||||
| AuthorizedOfficialFirstName: | SAIRAM | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8593417246 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 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 | 5124498 | 01 | CIGNA | OTHER | 65944233 | 05 | KY | MEDICAID | 2044773 | 05 | OH | MEDICAID | 728014 | 01 | BUCKEYE | OTHER | 610168000 | 01 | FEDERAL WORKERS COMP | OTHER |