Provider Demographics
NPI:1063510204
Name:TRI-STATE OB-GYN PC
Entity Type:Organization
Organization Name:TRI-STATE OB-GYN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:
Authorized Official - Last Name:LONDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-704-2229
Mailing Address - Street 1:3003 HIGHWAY 95
Mailing Address - Street 2:STE 31
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-7860
Mailing Address - Country:US
Mailing Address - Phone:928-704-2229
Mailing Address - Fax:928-704-2255
Practice Address - Street 1:3003 HIGHWAY 95
Practice Address - Street 2:STE 31
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-7860
Practice Address - Country:US
Practice Address - Phone:928-704-2229
Practice Address - Fax:928-704-2255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty