Basic Information
| Provider Information | |||||||||
| NPI: | 1528084704 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRI-STATE AUDIOLOGY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 499 COLLIERS WAY | ||||||||
| Address2: | |||||||||
| City: | WEIRTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 260625011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047231592 | ||||||||
| FaxNumber: | 3047231594 | ||||||||
| Practice Location | |||||||||
| Address1: | 499 COLLIERS WAY | ||||||||
| Address2: | |||||||||
| City: | WEIRTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 260625011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047231592 | ||||||||
| FaxNumber: | 3047231594 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 09/26/2007 | ||||||||
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| AuthorizedOfficialLastName: | HAWKINS | ||||||||
| AuthorizedOfficialFirstName: | JILL | ||||||||
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| AuthorizedOfficialTitleorPosition: | AUDIOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 3047231592 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | M.S., CCC-A | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | AUD800 | 01 | HEALTH PLAN OF UPPER OHIO | OTHER |