Provider Demographics
NPI:1275872038
Name:TRI-STATE PEDIATRIC ASSOCIATES, INC
Entity Type:Organization
Organization Name:TRI-STATE PEDIATRIC ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:NORMAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:MITRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-773-4776
Mailing Address - Street 1:15700 STATE STREET
Mailing Address - Street 2:ROUTE 170
Mailing Address - City:CALCUTTA
Mailing Address - State:OH
Mailing Address - Zip Code:43920
Mailing Address - Country:US
Mailing Address - Phone:330-385-1412
Mailing Address - Fax:724-774-2872
Practice Address - Street 1:15700 STATE STREET
Practice Address - Street 2:ROUTE 170
Practice Address - City:CALCUTTA
Practice Address - State:OH
Practice Address - Zip Code:43920
Practice Address - Country:US
Practice Address - Phone:330-385-1412
Practice Address - Fax:724-774-2872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-13
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9280534Medicare PIN