Provider Demographics
NPI:1922186378
Name:TRI-STATE ADVANCED PAIN MANAGEMENT PLLC
Entity Type:Organization
Organization Name:TRI-STATE ADVANCED PAIN MANAGEMENT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUK
Authorized Official - Middle Name:KI
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-684-5679
Mailing Address - Street 1:3332 VILLA PT
Mailing Address - Street 2:SUITE 104
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-7818
Mailing Address - Country:US
Mailing Address - Phone:270-684-5679
Mailing Address - Fax:270-684-5753
Practice Address - Street 1:3332 VILLA PT STE 104
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-7818
Practice Address - Country:US
Practice Address - Phone:270-684-5679
Practice Address - Fax:270-684-5753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64177280Medicaid
IN200426500AMedicaid
IN200426500AMedicaid
KY64177280Medicaid