Provider Demographics
NPI:1851543607
Name:TRI-STATE MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:TRI-STATE MEDICAL GROUP, INC
Other - Org Name:TSMG BOOK, BURK, AND INCORVATI SURGICAL ASSOCIATES
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 1:1520 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:PA
Mailing Address - Zip Code:15066-2204
Mailing Address - Country:US
Mailing Address - Phone:724-843-3800
Mailing Address - Fax:
Practice Address - Street 1:1520 3RD AVE
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:PA
Practice Address - Zip Code:15066-2204
Practice Address - Country:US
Practice Address - Phone:724-843-3800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRI-STATE MEDICAL GROUP, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-10
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0202677Medicaid
PA0015654460023Medicaid
PA0015654460023Medicaid