Provider Demographics
NPI:1841429099
Name:TRI-STATE MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:TRI-STATE MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
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 1:1185 FREEDOM RD
Mailing Address - Street 2:SUITE B106
Mailing Address - City:CRANBERRY TWP
Mailing Address - State:PA
Mailing Address - Zip Code:16066-4913
Mailing Address - Country:US
Mailing Address - Phone:724-773-5964
Mailing Address - Fax:
Practice Address - Street 1:1185 FREEDOM RD
Practice Address - Street 2:SUITE B106
Practice Address - City:CRANBERRY TWP
Practice Address - State:PA
Practice Address - Zip Code:16066-4913
Practice Address - Country:US
Practice Address - Phone:724-777-3596
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-09
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015654460023Medicaid
OH0202677Medicaid
OH0202677Medicaid
OH9280531Medicare PIN