Provider Demographics
NPI:1023618592
Name:TRI-STATE MEDICAL GROUP LLC
Entity type:Organization
Organization Name:TRI-STATE MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICAL
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:MORDUKHAYEV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-607-4491
Mailing Address - Street 1:2621 N FEDERAL HWY STE S
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-7785
Mailing Address - Country:US
Mailing Address - Phone:800-607-4491
Mailing Address - Fax:561-757-5850
Practice Address - Street 1:2621 N FEDERAL HWY STE S
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-7785
Practice Address - Country:US
Practice Address - Phone:800-607-4491
Practice Address - Fax:561-757-5850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies