Provider Demographics
NPI:1831146505
Name:TRI STATE GYNECOLOGY INC
Entity Type:Organization
Organization Name:TRI STATE GYNECOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:NORMAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:MITRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-773-4779
Mailing Address - Street 1:2 PEARTREE WAY
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:PA
Mailing Address - Zip Code:15009-1954
Mailing Address - Country:US
Mailing Address - Phone:724-728-4171
Mailing Address - Fax:724-728-2019
Practice Address - Street 1:690 STATE AVE
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:PA
Practice Address - Zip Code:15009-9501
Practice Address - Country:US
Practice Address - Phone:724-774-4546
Practice Address - Fax:724-774-9007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1010070720001Medicaid
PA083743Medicare ID - Type Unspecified