Provider Demographics
NPI:1881846624
Name:TRI-STATE PEDIATRIC ASSOCIATES, INC
Entity Type:Organization
Organization Name:TRI-STATE PEDIATRIC ASSOCIATES, INC
Other - Org Name:TSPEDS KASI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:NORMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MITRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-773-4776
Mailing Address - Street 1:3542 BRODHEAD RD
Mailing Address - Street 2:
Mailing Address - City:MONACA
Mailing Address - State:PA
Mailing Address - Zip Code:15061-3126
Mailing Address - Country:US
Mailing Address - Phone:724-775-9919
Mailing Address - Fax:
Practice Address - Street 1:3542 BRODHEAD RD
Practice Address - Street 2:
Practice Address - City:MONACA
Practice Address - State:PA
Practice Address - Zip Code:15061-3126
Practice Address - Country:US
Practice Address - Phone:724-775-9919
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRI-STATE PEDIATRIC ASSOCIATES, 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
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2023643Medicaid
PA1007289980010Medicaid
OH2023643Medicaid