Provider Demographics
NPI:1356706774
Name:TRISTATE MEDICAL SPECIALISTS LLC
Entity type:Organization
Organization Name:TRISTATE MEDICAL SPECIALISTS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOANN
Authorized Official - Middle Name:
Authorized Official - Last Name:VENGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-788-3333
Mailing Address - Street 1:PO BOX 10966
Mailing Address - Street 2:
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86427-0966
Mailing Address - Country:US
Mailing Address - Phone:928-788-3333
Mailing Address - Fax:928-788-3555
Practice Address - Street 1:1987 MCCULLOCH BLVD N
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5682
Practice Address - Country:US
Practice Address - Phone:928-788-3333
Practice Address - Fax:928-788-3555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-30
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207LP2900X, 2081P2900X, 208VP0014X, 208VP0000X
AZ20605207T00000X, 208VP0000X
AZAP3760363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
615056800OtherDOL
AZ079972Medicaid