Provider Demographics
NPI:1093180903
Name:TRI-STATE TELEMED LLC
Entity Type:Organization
Organization Name:TRI-STATE TELEMED LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:MAXEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-208-5978
Mailing Address - Street 1:620 PRIVATE ROAD 19423
Mailing Address - Street 2:
Mailing Address - City:SOUTH POINT
Mailing Address - State:OH
Mailing Address - Zip Code:45680-9019
Mailing Address - Country:US
Mailing Address - Phone:304-208-5978
Mailing Address - Fax:
Practice Address - Street 1:178 PRIVATE ROAD 19423
Practice Address - Street 2:
Practice Address - City:SOUTH POINT
Practice Address - State:OH
Practice Address - Zip Code:45680-8831
Practice Address - Country:US
Practice Address - Phone:304-208-5978
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-02
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY48537208D00000X
KY1121101363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty