Provider Demographics
NPI:1851467237
Name:TRI-STATE DIGESTIVE DISEASE ASSOC PSC.
Entity Type:Organization
Organization Name:TRI-STATE DIGESTIVE DISEASE ASSOC PSC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DON
Authorized Official - Last Name:CANTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-324-3188
Mailing Address - Street 1:617 23RD ST
Mailing Address - Street 2:SUITE 11
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-2880
Mailing Address - Country:US
Mailing Address - Phone:606-324-3188
Mailing Address - Fax:606-329-2237
Practice Address - Street 1:617 23RD ST
Practice Address - Street 2:SUIYE 11
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2845
Practice Address - Country:US
Practice Address - Phone:606-324-3188
Practice Address - Fax:606-329-2237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0126072Medicaid
KY65920845Medicaid
KY5258Medicare PIN
OH0126072Medicaid