Basic Information
| Provider Information | |||||||||
| NPI: | 1467946285 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRI STATE OBSTETRICS & GYNECOLOGY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GENERATIONS OB/GYN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 DUTCH RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | BEAVER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150099727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7247734776 | ||||||||
| FaxNumber: | 7247734726 | ||||||||
| Practice Location | |||||||||
| Address1: | 3468 BRODHEAD RD STE 12 | ||||||||
| Address2: | |||||||||
| City: | MONACA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150613149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7247283575 | ||||||||
| FaxNumber: | 7247707964 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2018 | ||||||||
| LastUpdateDate: | 07/01/2022 | ||||||||
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| AuthorizedOfficialLastName: | MITRY | ||||||||
| AuthorizedOfficialFirstName: | NORMAN | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 7247734776 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TRI STATE OBSTETRICS & GYNECOLOGY | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 001548632 | 05 | PA | MEDICAID |