Basic Information
| Provider Information | |||||||||
| NPI: | 1609962067 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRI STATE NEUROSCIENCE CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3107 | ||||||||
| Address2: | 2860 3RD AVE SUITE 10 | ||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045256825 | ||||||||
| FaxNumber: | 3045250300 | ||||||||
| Practice Location | |||||||||
| Address1: | 2860 3RD AVE | ||||||||
| Address2: | SUITE 10 | ||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045256825 | ||||||||
| FaxNumber: | 3045250300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ABBOTT | ||||||||
| AuthorizedOfficialFirstName: | ERMA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3045256825 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0883745 | 01 | OH | MEDICAID | OTHER |