Provider Demographics
NPI:1114927209
Name:TRISTATE IMG (IMAGING MEDICAL GROUP) INC
Entity Type:Organization
Organization Name:TRISTATE IMG (IMAGING MEDICAL GROUP) INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLIENT SERVICES MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-965-8041
Mailing Address - Street 1:PO BOX 42456
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45242-0456
Mailing Address - Country:US
Mailing Address - Phone:513-965-8041
Mailing Address - Fax:513-965-8091
Practice Address - Street 1:375 DIXMYTH AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45220
Practice Address - Country:US
Practice Address - Phone:513-965-8041
Practice Address - Fax:513-965-8091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-29
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0318981Medicaid
IN100002830AMedicaid
KY65920043Medicaid
OHCE9205Medicare PIN
OH9177511Medicare PIN