Provider Demographics
NPI:1194182188
Name:TRI COUNTY MEDICAL LLC
Entity Type:Organization
Organization Name:TRI COUNTY MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-697-3668
Mailing Address - Street 1:7611 PERSHING BLVD
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-4317
Mailing Address - Country:US
Mailing Address - Phone:262-697-3668
Mailing Address - Fax:262-697-3500
Practice Address - Street 1:4310 W CRYSTAL LAKE RD
Practice Address - Street 2:SUITE F
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-4214
Practice Address - Country:US
Practice Address - Phone:815-363-3223
Practice Address - Fax:815-363-3240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-21
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIT059603261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical