Provider Demographics
NPI:1215363254
Name:TRI-STATE HEALTHY
Entity Type:Organization
Organization Name:TRI-STATE HEALTHY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEKSANDR
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIROSOV
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:201-791-7771
Mailing Address - Street 1:554 BLOOMFIELD AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-3307
Mailing Address - Country:US
Mailing Address - Phone:201-791-7771
Mailing Address - Fax:201-791-7337
Practice Address - Street 1:554 BLOOMFIELD AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-3307
Practice Address - Country:US
Practice Address - Phone:201-791-7771
Practice Address - Fax:201-791-7337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-23
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ026128R77Medicare PIN