Provider Demographics
NPI:1275785057
Name:TRI-STATE MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:TRI-STATE MEDICAL GROUP, INC.
Other - Org Name:TSMG CENTER MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:NORMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MITRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-773-4776
Mailing Address - Street 1:99 AUTUMN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ALIQUIPPA
Mailing Address - State:PA
Mailing Address - Zip Code:15001-1301
Mailing Address - Country:US
Mailing Address - Phone:724-375-3100
Mailing Address - Fax:
Practice Address - Street 1:99 AUTUMN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:ALIQUIPPA
Practice Address - State:PA
Practice Address - Zip Code:15001-1301
Practice Address - Country:US
Practice Address - Phone:724-375-3100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRI-STATE MEDICAL GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-13
Last Update Date:2008-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015654460023Medicaid
OH0202677Medicaid
PA807864Medicare PIN