Provider Demographics
NPI:1861642738
Name:TRI-STATE PEDIATRIC ASSOCIATES
Entity Type:Organization
Organization Name:TRI-STATE PEDIATRIC ASSOCIATES
Other - Org Name:TRI-STATE PEDIATRICS NORTH HILLS
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 1:119 VIP DR
Mailing Address - Street 2:SUITE G4
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-7976
Mailing Address - Country:US
Mailing Address - Phone:724-934-2273
Mailing Address - Fax:724-934-2375
Practice Address - Street 1:119 VIP DR
Practice Address - Street 2:SUITE G4
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-7976
Practice Address - Country:US
Practice Address - Phone:724-934-2273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRI STATE PEDIATRIC ASSOCIATES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-26
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA807864Medicare PIN