Provider Demographics
NPI:1437301280
Name:TRI-STATE MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:TRI-STATE MEDICAL GROUP, INC.
Other - Org Name:TSMG BIMA BEAVER FALLS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:NORMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MITRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-773-4776
Mailing Address - Street 1:1307 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVER FALLS
Mailing Address - State:PA
Mailing Address - Zip Code:15010-4213
Mailing Address - Country:US
Mailing Address - Phone:724-843-4700
Mailing Address - Fax:
Practice Address - Street 1:1307 6TH AVE
Practice Address - Street 2:
Practice Address - City:BEAVER FALLS
Practice Address - State:PA
Practice Address - Zip Code:15010-4213
Practice Address - Country:US
Practice Address - Phone:724-843-4700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRI-STATE MEDICAL GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-10
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0202677Medicaid
PA0015654460023Medicaid
PA0015654460023Medicaid