Provider Demographics
NPI:1922186006
Name:TRI-STATE MEDICAL GROUP INC
Entity Type:Organization
Organization Name:TRI-STATE MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ALLAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:ZASTROW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-524-7150
Mailing Address - Street 1:400 N 17TH ST
Mailing Address - Street 2:
Mailing Address - City:KEOKUK
Mailing Address - State:IA
Mailing Address - Zip Code:52632-3452
Mailing Address - Country:US
Mailing Address - Phone:319-524-5734
Mailing Address - Fax:319-524-5758
Practice Address - Street 1:1603 MORGAN ST
Practice Address - Street 2:SUITE 7
Practice Address - City:KEOKUK
Practice Address - State:IA
Practice Address - Zip Code:52632-3433
Practice Address - Country:US
Practice Address - Phone:319-524-5734
Practice Address - Fax:319-524-5758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA25523207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty