Provider Demographics
NPI:1457321721
Name:TRI-STATE EAR, NOSE, AND THROAT SURGEONS, INC.
Entity Type:Organization
Organization Name:TRI-STATE EAR, NOSE, AND THROAT SURGEONS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:T
Authorized Official - Last Name:WAHLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-425-4646
Mailing Address - Street 1:350 W COLUMBIA ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47710-1782
Mailing Address - Country:US
Mailing Address - Phone:812-425-4646
Mailing Address - Fax:812-467-7209
Practice Address - Street 1:350 W COLUMBIA ST
Practice Address - Street 2:SUITE 310
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47710-1782
Practice Address - Country:US
Practice Address - Phone:812-425-4646
Practice Address - Fax:812-467-7209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-26
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50001145A207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100241980Medicaid
IN100241980Medicaid
IN637200Medicare PIN