Provider Demographics
NPI:1013098904
Name:TRI-STATE PEDIATRICS
Entity Type:Organization
Organization Name:TRI-STATE PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING CLERK
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:SISLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-836-0919
Mailing Address - Street 1:900 SAINT CHRISTOPHER DR
Mailing Address - Street 2:BUILDING 4 SUITE 101
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-7090
Mailing Address - Country:US
Mailing Address - Phone:606-836-0919
Mailing Address - Fax:606-836-2847
Practice Address - Street 1:900 SAINT CHRISTOPHER DR
Practice Address - Street 2:BUILDING 4 SUITE 101
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-7090
Practice Address - Country:US
Practice Address - Phone:606-836-0919
Practice Address - Fax:606-836-2847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY25781174400000X
KY02639174400000X
KY38597174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64011059Medicaid
KY02639OtherKY LICENSE
KY38597OtherKY LICENSE
KY64066384Medicaid
OH2271429Medicaid
OH0665310Medicaid
KY25781OtherKY LICENSE
KY64257819Medicaid
G05276Medicare UPIN
KYC03231Medicare UPIN
KY64257819Medicaid
H90134Medicare UPIN