Provider Demographics
NPI:1225016298
Name:TRI STATE PRIMARY CARE LLC
Entity Type:Organization
Organization Name:TRI STATE PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER PHYSICIAN PRACTICE
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BERNENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-559-2891
Mailing Address - Street 1:PO BOX 633359
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-3359
Mailing Address - Country:US
Mailing Address - Phone:513-557-3330
Mailing Address - Fax:513-557-3199
Practice Address - Street 1:4010 N BEND RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45211-3500
Practice Address - Country:US
Practice Address - Phone:513-598-3500
Practice Address - Fax:513-598-3508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-09
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2327682Medicaid
IN200415580BMedicaid
IN200415580AMedicaid
KY65939001Medicaid
OH9325821Medicare PIN
OHCK4249Medicare PIN
IN200415580AMedicaid