Provider Demographics
NPI:1437435161
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:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:NORMAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:MITRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-773-4776
Mailing Address - Street 1:3468 BRODHEAD RD
Mailing Address - Street 2:
Mailing Address - City:MONACA
Mailing Address - State:PA
Mailing Address - Zip Code:15061-3149
Mailing Address - Country:US
Mailing Address - Phone:724-857-0591
Mailing Address - Fax:
Practice Address - Street 1:3468 BRODHEAD RD
Practice Address - Street 2:
Practice Address - City:MONACA
Practice Address - State:PA
Practice Address - Zip Code:15061-3149
Practice Address - Country:US
Practice Address - Phone:724-857-0591
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HERITAGE VALLEY PRIMARY CARE-CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty