Provider Demographics
NPI:1902200876
Name:TRI-STATE SPORT AND SPINE, PLLC
Entity Type:Organization
Organization Name:TRI-STATE SPORT AND SPINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:DOUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:215-251-8526
Mailing Address - Street 1:110 WHARTON ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-5425
Mailing Address - Country:US
Mailing Address - Phone:215-251-8526
Mailing Address - Fax:215-673-1980
Practice Address - Street 1:9331 OLD BUSTLETON AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-4204
Practice Address - Country:US
Practice Address - Phone:215-251-8526
Practice Address - Fax:215-673-1980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-21
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC010688111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty