Provider Demographics
NPI:1679503726
Name:TRI STATE MEDICAL ASSOC. P.C.
Entity Type:Organization
Organization Name:TRI STATE MEDICAL ASSOC. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:C
Authorized Official - Last Name:AUERBACH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:579-491-4164
Mailing Address - Street 1:906 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:MATAMORAS
Mailing Address - State:PA
Mailing Address - Zip Code:18336-1542
Mailing Address - Country:US
Mailing Address - Phone:579-491-4164
Mailing Address - Fax:570-491-5186
Practice Address - Street 1:906 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:MATAMORAS
Practice Address - State:PA
Practice Address - Zip Code:18336-1542
Practice Address - Country:US
Practice Address - Phone:579-491-4164
Practice Address - Fax:570-491-5186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOSOO4513LL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA165007OtherFIRST PRIORITY
PACD3145OtherRAIL ROAD MEDICARE
PA37785OtherPA BLUE SHIELD
PA0064202000OtherPERSONAL CHOICE
PA117236OtherMVP HEALTHCARE
PA7001046Medicaid
PACD3145OtherRAIL ROAD MEDICARE
PA117236OtherMVP HEALTHCARE