Provider Demographics
NPI:1477993939
Name:TRI STATE IMMUNIZATION GROUP INC
Entity Type:Organization
Organization Name:TRI STATE IMMUNIZATION GROUP INC
Other - Org Name:PASSPORT HEALTH OF EVANSVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:R
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-402-6000
Mailing Address - Street 1:101 PLAZA EAST BLVD
Mailing Address - Street 2:STE 107
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-2804
Mailing Address - Country:US
Mailing Address - Phone:812-402-6000
Mailing Address - Fax:812-402-6012
Practice Address - Street 1:101 PLAZA EAST BOULEVARD
Practice Address - Street 2:STE 107
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-2804
Practice Address - Country:US
Practice Address - Phone:812-402-6000
Practice Address - Fax:812-402-6012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-28
Last Update Date:2013-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty