Provider Demographics
NPI:1457301939
Name:TRI-STATE COMMUNITY HEALTH CENTER, INC
Entity Type:Organization
Organization Name:TRI-STATE COMMUNITY HEALTH CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:J
Authorized Official - Last Name:DESHONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-678-7256
Mailing Address - Street 1:130 W HIGH ST
Mailing Address - Street 2:
Mailing Address - City:HANCOCK
Mailing Address - State:MD
Mailing Address - Zip Code:21750-1143
Mailing Address - Country:US
Mailing Address - Phone:301-678-7256
Mailing Address - Fax:301-678-8007
Practice Address - Street 1:621 KELLY RD
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-2878
Practice Address - Country:US
Practice Address - Phone:301-722-3270
Practice Address - Fax:301-722-3276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1723320/02Medicaid
WV0035061003Medicaid
MD482501201Medicaid
PA1723320/02Medicaid
MDS865Medicare PIN
MD482501201Medicaid