Provider Demographics
NPI:1205825122
Name:TRI-STATE PEDIATRIC OPHTHALMOLOGY, LLC
Entity Type:Organization
Organization Name:TRI-STATE PEDIATRIC OPHTHALMOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:M
Authorized Official - Last Name:GAINER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:740-633-6671
Mailing Address - Street 1:222 N 5TH ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MARTINS FERRY
Mailing Address - State:OH
Mailing Address - Zip Code:43935-1582
Mailing Address - Country:US
Mailing Address - Phone:740-633-6671
Mailing Address - Fax:740-633-6679
Practice Address - Street 1:222 N 5TH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:MARTINS FERRY
Practice Address - State:OH
Practice Address - Zip Code:43935-1582
Practice Address - Country:US
Practice Address - Phone:740-633-6671
Practice Address - Fax:740-633-6679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-14
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-84204207W00000X
WV20425207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2003963000Medicaid
OH2524209Medicaid
WV2003963000Medicaid
OH9351751Medicare PIN
OH2524209Medicaid