Provider Demographics
NPI:1790019438
Name:TRI-STATE MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:TRI-STATE MEDICAL GROUP, INC.
Other - Org Name:HERITAGE VALLEY REHABILITATION MEDICINE BEAVER
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 1:1030 BEANER HOLLOW ROAD
Mailing Address - Street 2:BEAVER MEDICAL COMMONS
Mailing Address - City:BEAVER
Mailing Address - State:PA
Mailing Address - Zip Code:15009
Mailing Address - Country:US
Mailing Address - Phone:724-770-0410
Mailing Address - Fax:724-770-0414
Practice Address - Street 1:1030 BEANER HOLLOW ROAD
Practice Address - Street 2:BEAVER MEDICAL COMMONS
Practice Address - City:BEAVER
Practice Address - State:PA
Practice Address - Zip Code:15009
Practice Address - Country:US
Practice Address - Phone:724-770-0410
Practice Address - Fax:724-770-0414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-29
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD432785208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015654460023Medicaid
OH0202677Medicaid
PA0015654460023Medicaid
OH9280531Medicare PIN