Provider Demographics
NPI:1598164337
Name:TRICORNE PRIMARY NERVE & JOINT, LLC
Entity Type:Organization
Organization Name:TRICORNE PRIMARY NERVE & JOINT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:EARL
Authorized Official - Middle Name:W
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:717-747-3220
Mailing Address - Street 1:2200 S GEORGE ST
Mailing Address - Street 2:SUITE W-2
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17403-4594
Mailing Address - Country:US
Mailing Address - Phone:717-747-3220
Mailing Address - Fax:717-747-3338
Practice Address - Street 1:2200 S GEORGE ST
Practice Address - Street 2:SUITE W-2
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-4594
Practice Address - Country:US
Practice Address - Phone:717-747-3220
Practice Address - Fax:717-747-3338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-18
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD427825261QH0100X, 261QM1300X, 261QP2300X, 302R00000X, 305R00000X, 305S00000X
PABE8901060261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
No305R00000XManaged Care OrganizationsPreferred Provider Organization
No305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0090250OtherMEDICARE ID
PA0090250OtherMEDICARE ID