Provider Demographics
NPI:1356494876
Name:TRI-STATE UROLOGY
Entity Type:Organization
Organization Name:TRI-STATE UROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:SWOFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:606-437-9550
Mailing Address - Street 1:PO BOX 2438
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41502-2438
Mailing Address - Country:US
Mailing Address - Phone:606-437-9550
Mailing Address - Fax:606-437-9510
Practice Address - Street 1:255 CHURCH ST
Practice Address - Street 2:STE. 202
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-3476
Practice Address - Country:US
Practice Address - Phone:606-437-9550
Practice Address - Fax:606-437-9510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02625208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65935009Medicaid
KY1245238484Medicaid
KY1245238484Medicaid
KY6803Medicare PIN
KYF59735Medicare UPIN