Provider Demographics
NPI:1083130751
Name:TRI-STATE COLORECTAL GROUP, LLC
Entity Type:Organization
Organization Name:TRI-STATE COLORECTAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:DEANE
Authorized Official - Middle Name:L
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:812-301-8110
Mailing Address - Street 1:950 S KENMORE DR STE B
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47714-7513
Mailing Address - Country:US
Mailing Address - Phone:812-301-8110
Mailing Address - Fax:812-401-4001
Practice Address - Street 1:950 S KENMORE DR STE B
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-7513
Practice Address - Country:US
Practice Address - Phone:812-301-8110
Practice Address - Fax:812-401-4001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-15
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty