Provider Demographics
NPI:1487651956
Name:TRI-STATE GASTROENTEROLOGY ASSOCIATES, PSC
Entity Type:Organization
Organization Name:TRI-STATE GASTROENTEROLOGY ASSOCIATES, PSC
Other - Org Name:TRI-STATE DIGESTIVE DISORDER CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:FAGEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-341-3575
Mailing Address - Street 1:425 CENTRE VIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW HILLS
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3409
Mailing Address - Country:US
Mailing Address - Phone:859-341-3575
Mailing Address - Fax:859-341-5702
Practice Address - Street 1:425 CENTRE VIEW BLVD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-3409
Practice Address - Country:US
Practice Address - Phone:859-341-3575
Practice Address - Fax:859-341-5702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY300096261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200354210AMedicaid
000000003071OtherANTHEM
490002071OtherMEDICARE RAILROAD
KY7100169710Medicaid
000000003071OtherANTHEM
KY7100169710Medicaid
KYASC0020Medicare PIN