Provider Demographics
NPI:1598763104
Name:TRISTATE MATERNAL FETAL MEDICINE INC
Entity Type:Organization
Organization Name:TRISTATE MATERNAL FETAL MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCLINTOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-862-6200
Mailing Address - Street 1:PO BOX 9493
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-9493
Mailing Address - Country:US
Mailing Address - Phone:513-862-6200
Mailing Address - Fax:513-862-4358
Practice Address - Street 1:375 DIXMYTH AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45220-2475
Practice Address - Country:US
Practice Address - Phone:513-862-6300
Practice Address - Fax:513-862-4358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-08
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200086360AMedicaid
OH0195551Medicaid
MI4805896Medicaid
KY65925679Medicaid
IN200086360AMedicaid
KY65925679Medicaid
OH0195551Medicaid