Provider Demographics
NPI:1609825652
Name:TRI STATE DIAGNOSTIC SERVICES , INC
Entity Type:Organization
Organization Name:TRI STATE DIAGNOSTIC SERVICES , INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD: AUTHORIZED SIGNATORY
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEALY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-451-1930
Mailing Address - Street 1:PO BOX 932321
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0001
Mailing Address - Country:US
Mailing Address - Phone:513-853-5000
Mailing Address - Fax:
Practice Address - Street 1:2446 KIPLING AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45239-6650
Practice Address - Country:US
Practice Address - Phone:513-853-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0918654Medicaid
OH0922283Medicaid
OH0918654Medicaid
OH0922283Medicaid