Provider Demographics
NPI:1316025760
Name:TRI-STATE SURGICAL CENTER, LLC
Entity Type:Organization
Organization Name:TRI-STATE SURGICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TROY
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-267-0556
Mailing Address - Street 1:1006 TAVERN RD
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-2864
Mailing Address - Country:US
Mailing Address - Phone:304-267-0556
Mailing Address - Fax:
Practice Address - Street 1:1006 TAVERN RD
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-2864
Practice Address - Country:US
Practice Address - Phone:304-267-0556
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19418-23067261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV6905041000Medicaid
WV5110141Medicare ID - Type UnspecifiedFACILITY PROVIDER NUMBER