Provider Demographics
NPI:1972540953
Name:TRI-STATE GASTROENTEROLOGY, P.C.
Entity Type:Organization
Organization Name:TRI-STATE GASTROENTEROLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:WASHINGTON
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-398-9574
Mailing Address - Street 1:1264 WESLEY DR
Mailing Address - Street 2:SUITE 303
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38116-6400
Mailing Address - Country:US
Mailing Address - Phone:901-398-9574
Mailing Address - Fax:901-398-9581
Practice Address - Street 1:1264 WESLEY DR
Practice Address - Street 2:SUITE 303
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-6400
Practice Address - Country:US
Practice Address - Phone:901-398-9574
Practice Address - Fax:901-398-9581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3708237Medicare ID - Type Unspecified