Provider Demographics
NPI:1295746691
Name:TRISTATE ORTHOPAEDIC TREATMENT CENTER, INC.
Entity type:Organization
Organization Name:TRISTATE ORTHOPAEDIC TREATMENT CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLYDE
Authorized Official - Middle Name:E
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:513-791-6611
Mailing Address - Street 1:10547 MONTGOMERY ROAD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45242-4418
Mailing Address - Country:US
Mailing Address - Phone:513-791-6611
Mailing Address - Fax:513-791-6788
Practice Address - Street 1:10547 MONTGOMERY ROAD
Practice Address - Street 2:SUITE 400
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45242-4418
Practice Address - Country:US
Practice Address - Phone:513-791-6611
Practice Address - Fax:513-791-6788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0946007Medicaid
IN200025270BMedicaid
IN200025270DMedicaid
IN200025270CMedicaid
OH0946007Medicaid
INM100018248Medicare PIN
OHTR9926892Medicare ID - Type Unspecified
OH0190590001Medicare NSC
IN0190590002Medicare NSC
IN200025270CMedicaid