Basic Information
| Provider Information | |||||||||
| NPI: | 1851525539 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRISTATE ASSOC OF INTERNAL MEDICINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3276 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477313276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124730181 | ||||||||
| FaxNumber: | 8124735822 | ||||||||
| Practice Location | |||||||||
| Address1: | 827 S GREEN RIVER RD | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477154105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124911307 | ||||||||
| FaxNumber: | 8124737226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2009 | ||||||||
| LastUpdateDate: | 07/14/2021 | ||||||||
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| AuthorizedOfficialLastName: | GURRAM | ||||||||
| AuthorizedOfficialFirstName: | SUDHEER | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8124911307 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D.,F.A.C.P | ||||||||
| NPICertificationDate: | 07/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 01040825 | IN | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.