Provider Demographics
NPI:1578921359
Name:TRI-STATE SPORT AND SPINE, PLLC
Entity Type:Organization
Organization Name:TRI-STATE SPORT AND SPINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:609-760-0386
Mailing Address - Street 1:110 WHARTON ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-5425
Mailing Address - Country:US
Mailing Address - Phone:609-760-0386
Mailing Address - Fax:
Practice Address - Street 1:100 SOUTH BROAD STREET
Practice Address - Street 2:1800
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19110
Practice Address - Country:US
Practice Address - Phone:215-988-9503
Practice Address - Fax:215-988-9533
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRI-STATE SPORT AND SPINE, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-02-08
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC010688111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty