Provider Demographics
NPI:1619116738
Name:TRI-STATE MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:TRI-STATE MEDICAL GROUP, INC.
Other - Org Name:HERITAGE VALLEY FAMILY PRACTICE GRIECO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:NORMAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:MITRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-773-4776
Mailing Address - Street 1:2620 CONSTITUTION BLVD
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:BEAVER FALLS
Mailing Address - State:PA
Mailing Address - Zip Code:15010-1278
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2620 CONSTITUTION BLVD
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:BEAVER FALLS
Practice Address - State:PA
Practice Address - Zip Code:15010-1278
Practice Address - Country:US
Practice Address - Phone:724-775-6500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-12
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015654460023Medicaid
PA807864Medicare PIN