Basic Information
| Provider Information | |||||||||
| NPI: | 1700823275 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRI-STATE RADIOLOGY, PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2408 | ||||||||
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| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411052408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063274633 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2201 LEXINGTON AVE | ||||||||
| Address2: | KINGS DAUGHTER MEDICAL CENTER | ||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411012843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068335741 | ||||||||
| FaxNumber: | 8592232732 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 11/15/2007 | ||||||||
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| AuthorizedOfficialLastName: | BOYKIN | ||||||||
| AuthorizedOfficialFirstName: | CANDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | GROUP PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6063274633 | ||||||||
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| 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 | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 65927279 | 05 | KY | MEDICAID |