Provider Demographics
NPI:1326027756
Name:TRI-STATE MEDICAL GROUP INC
Entity Type:Organization
Organization Name:TRI-STATE MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:ASBURY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-526-8789
Mailing Address - Street 1:400 N 17TH ST
Mailing Address - Street 2:
Mailing Address - City:KEOKUK
Mailing Address - State:IA
Mailing Address - Zip Code:52632-3452
Mailing Address - Country:US
Mailing Address - Phone:319-524-5734
Mailing Address - Fax:319-524-5758
Practice Address - Street 1:1603 MORGAN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:KEOKUK
Practice Address - State:IA
Practice Address - Zip Code:52632-3433
Practice Address - Country:US
Practice Address - Phone:319-524-4300
Practice Address - Fax:319-524-4424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-13
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18997208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0145888Medicaid
56343OtherWELLMARK
IA56343OtherBC/BS
MO=========Medicaid
IAO80093587Medicare ID - Type UnspecifiedRAILROAD MEDICARE
IA56343Medicare PIN