Provider Demographics
NPI:1255646485
Name:TRI STATE INTERNAL MEDICINE SOURCE
Entity type:Organization
Organization Name:TRI STATE INTERNAL MEDICINE SOURCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:L
Authorized Official - Last Name:KLING-TIPTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-477-4375
Mailing Address - Street 1:3700 BELLEMEADE AVE
Mailing Address - Street 2:STE 119
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47714-0102
Mailing Address - Country:US
Mailing Address - Phone:812-477-4375
Mailing Address - Fax:812-477-3375
Practice Address - Street 1:3700 BELLEMEADE AVE
Practice Address - Street 2:STE 119
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-0102
Practice Address - Country:US
Practice Address - Phone:812-477-4375
Practice Address - Fax:812-477-3375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-12
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty