Basic Information
| Provider Information | |||||||||
| NPI: | 1962429647 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRI-STATE CARDIOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2408 SUSANNAH ST | ||||||||
| Address2: | STE.1 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376011728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232825054 | ||||||||
| FaxNumber: | 4232620220 | ||||||||
| Practice Location | |||||||||
| Address1: | 2408 SUSANNAH ST | ||||||||
| Address2: | STE.1 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376011728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232825054 | ||||||||
| FaxNumber: | 4232620220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SEXTON | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4232825054 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 4058472 | 01 | TN | BCBS | OTHER |