Provider Demographics
NPI:1649217910
Name:TRI-STATE VASCULAR GROUP, PSC
Entity Type:Organization
Organization Name:TRI-STATE VASCULAR GROUP, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/VASCULAR SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:OMRAN
Authorized Official - Middle Name:RIAD
Authorized Official - Last Name:ABUL-KHOUDOUD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-326-1675
Mailing Address - Street 1:PO BOX 149
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-0149
Mailing Address - Country:US
Mailing Address - Phone:606-326-1675
Mailing Address - Fax:606-326-1436
Practice Address - Street 1:2301 LEXINGTON AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2873
Practice Address - Country:US
Practice Address - Phone:606-326-1675
Practice Address - Fax:606-326-1436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY40007174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000484792OtherBLUE CROSS BLUE SHIELD
KY7499265OtherAETNA
KY65945495Medicaid
OH2645436Medicaid
KYDF0183OtherMEDICARE RR
KY65945495Medicaid
KY7499265OtherAETNA