TRI-STATE MEDICAL GROUP, INC

Provider Demographics

• NPI: 1508001538
• Name: TRI-STATE MEDICAL GROUP, INC
• Entity Type: Organization
• Organization Name: TRI-STATE MEDICAL GROUP, INC
• Other - Org Name: CONVENIENT CARE CENTER-BEAVER
• Other - Org Type: Doing Business As
• Authorized Official - Title/Position: PRESIDENT & CEO
• Authorized Official - Prefix: MR
• Authorized Official - First Name: NORMAN
• Authorized Official - Middle Name: F
• Authorized Official - Last Name: MITRY
• Authorized Official - Phone: 724-773-4776
• Mailing Address - Street 1: 274 3RD ST
• Mailing Address - Street 2: SUITE 100
• Mailing Address - City: BEAVER
• Mailing Address - State: PA
• Mailing Address - Zip Code: 15009-2333
• Mailing Address - Country: US
• Mailing Address - Phone: 724-774-2942
• Mailing Address - Fax: 724-774-2942
• Practice Address - Street 1: 274 3RD ST
• Practice Address - Street 2: SUITE 100
• Practice Address - City: BEAVER
• Practice Address - State: PA
• Practice Address - Zip Code: 15009-2333
• Practice Address - Country: US
• Practice Address - Phone: 724-774-2942
• Practice Address - Fax: 724-774-2942
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2008-12-04
• Last Update Date: 2008-12-04

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	363L00000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner		Group - Multi-Specialty
No	207Q00000X	Allopathic & Osteopathic Physicians	Family Medicine		Group - Multi-Specialty
No	207R00000X	Allopathic & Osteopathic Physicians	Internal Medicine		Group - Multi-Specialty
No	208000000X	Allopathic & Osteopathic Physicians	Pediatrics		Group - Multi-Specialty
No	363A00000X	Physician Assistants & Advanced Practice Nursing Providers	Physician Assistant		Group - Multi-Specialty
No	363AM0700X	Physician Assistants & Advanced Practice Nursing Providers	Physician Assistant	Medical	Group - Multi-Specialty
No	363LF0000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Family	Group - Multi-Specialty
No	363LP0200X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Pediatrics	Group - Multi-Specialty
No	363LP2300X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Primary Care	Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
PA	0015654460023	Medicaid
PA	0015486320010	Medicaid
OH	0202677	Medicaid
PA	1007289980010	Medicaid
PA	015888	Medicare PIN
PA	1007289980010	Medicaid
PA	808839	Medicare PIN