Provider Demographics
NPI:1306843842
Name:TRI-STATE GASTROENTEROLOGY ASSOCIATES, PSC
Entity Type:Organization
Organization Name:TRI-STATE GASTROENTEROLOGY ASSOCIATES, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:FAGEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-341-3575
Mailing Address - Street 1:425 CENTRE VIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW HILLS
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3409
Mailing Address - Country:US
Mailing Address - Phone:859-341-3575
Mailing Address - Fax:859-341-5701
Practice Address - Street 1:425 CENTRE VIEW BLVD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-3409
Practice Address - Country:US
Practice Address - Phone:859-341-3575
Practice Address - Fax:859-341-5701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200354220Medicaid
000000032466OtherANTHEM
KY6591623100Medicaid
KY78901550OtherKY MEDICAID NP GROUP
CM0475OtherMEDICARE RAILROAD
OH0835841Medicaid
KY7100179230OtherKY MEDICAID PA GROUP
KY6591623100Medicaid