Provider Demographics
NPI:1205006962
Name:TRI-STATE EECP
Entity Type:Organization
Organization Name:TRI-STATE EECP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:H
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-522-3773
Mailing Address - Street 1:PO BOX 997
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25713-0997
Mailing Address - Country:US
Mailing Address - Phone:304-522-3773
Mailing Address - Fax:
Practice Address - Street 1:2900 1ST AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702-1241
Practice Address - Country:US
Practice Address - Phone:304-522-3773
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-08
Last Update Date:2008-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV18236207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVG20573Medicare UPIN
WV9350781Medicare PIN
WV0793756Medicare PIN