Provider Demographics
NPI:1659709277
Name:TRI-STATE COMMUNITY HEALTH CENTER, INC
Entity Type:Organization
Organization Name:TRI-STATE COMMUNITY HEALTH CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HR MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SATRICIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:WOODAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-678-5187
Mailing Address - Street 1:109 RAYLOC DR
Mailing Address - Street 2:
Mailing Address - City:HANCOCK
Mailing Address - State:MD
Mailing Address - Zip Code:21750-1518
Mailing Address - Country:US
Mailing Address - Phone:301-678-5187
Mailing Address - Fax:301-678-5797
Practice Address - Street 1:621 KELLY RD
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-2878
Practice Address - Country:US
Practice Address - Phone:301-722-3270
Practice Address - Fax:301-678-3276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR200178363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD211828OtherMEDICARE FQHC