Provider Demographics
NPI:1114258142
Name:TRI-STATE PAIN MANAGEMENT SERVICE INC
Entity Type:Organization
Organization Name:TRI-STATE PAIN MANAGEMENT SERVICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAIRAM
Authorized Official - Middle Name:L
Authorized Official - Last Name:ATLURI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-341-7246
Mailing Address - Street 1:# L-6067
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45270-0001
Mailing Address - Country:US
Mailing Address - Phone:859-341-7246
Mailing Address - Fax:859-341-7867
Practice Address - Street 1:8250 KENWOOD CROSSING WAY
Practice Address - Street 2:STE 101
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45236
Practice Address - Country:US
Practice Address - Phone:859-341-7246
Practice Address - Fax:859-341-7867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-14
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2044773Medicaid
284941995OtherHEALTHLAB GROUP#
KY65944233Medicaid
728014OtherBUCKEYE
5124498OtherCIGNA
000000388145OtherANTHEM
284941995OtherHEALTHNET
28494199500OtherBUREAU OF WORKERS COMP
IN200377720Medicaid
5124498OtherCIGNA
284941995OtherHEALTHNET