Provider Demographics
NPI:1598885998
Name:TRI-RIVERS HEALTHCARE PLLC
Entity Type:Organization
Organization Name:TRI-RIVERS HEALTHCARE PLLC
Other - Org Name:SMITHLAND MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AGENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ALBIN
Authorized Official - Last Name:HENEISEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-988-3298
Mailing Address - Street 1:141 HOSPITAL DRIVE
Mailing Address - Street 2:PO BOX 347
Mailing Address - City:SALEM
Mailing Address - State:KY
Mailing Address - Zip Code:42078-0347
Mailing Address - Country:US
Mailing Address - Phone:270-988-3298
Mailing Address - Fax:270-988-4642
Practice Address - Street 1:205 E ADAIR ST
Practice Address - Street 2:
Practice Address - City:SMITHLAND
Practice Address - State:KY
Practice Address - Zip Code:42081-9507
Practice Address - Country:US
Practice Address - Phone:270-928-2146
Practice Address - Fax:270-928-4492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207R00000X, 208600000X, 208D00000X, 363LF0000X
KY900217261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7890094100Medicaid
KY7100091610Medicaid
KY6590103500Medicaid
KY183962Medicare Oscar/Certification
KYX46707Medicare UPIN
KY7100091610Medicaid
KY6273Medicare PIN