Provider Demographics
NPI:1366849283
Name:TRI STATE NEUROLOGY, PLLC
Entity Type:Organization
Organization Name:TRI STATE NEUROLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:DEITCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-836-5565
Mailing Address - Street 1:1450 DIEDERICH BLVD
Mailing Address - Street 2:
Mailing Address - City:RUSSELL
Mailing Address - State:KY
Mailing Address - Zip Code:41169-1719
Mailing Address - Country:US
Mailing Address - Phone:606-836-5565
Mailing Address - Fax:606-836-5567
Practice Address - Street 1:1450 DIEDERICH BLVD
Practice Address - Street 2:
Practice Address - City:RUSSELL
Practice Address - State:KY
Practice Address - Zip Code:41169-1719
Practice Address - Country:US
Practice Address - Phone:606-836-5565
Practice Address - Fax:606-836-5567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-20
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY265352084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty