Provider Demographics
NPI:1649312083
Name:TRI- STATE ALLERGY, INC
Entity type:Organization
Organization Name:TRI- STATE ALLERGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:C
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-529-6100
Mailing Address - Street 1:1001 20TH ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25703-2019
Mailing Address - Country:US
Mailing Address - Phone:304-529-6100
Mailing Address - Fax:304-529-0229
Practice Address - Street 1:3752 TEAYS VALLEY RD STE 3
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9705
Practice Address - Country:US
Practice Address - Phone:304-529-6100
Practice Address - Fax:304-529-0229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHL0489556Medicaid
OHL0874442Medicaid
WV0044083000Medicaid
WV0070510000Medicaid
OHL0489556Medicaid
WVPR9263351Medicare ID - Type UnspecifiedPALMETTO GROUP
OHL0968403Medicare ID - Type UnspecifiedPERSONAL
WVF39127Medicare UPIN
WV0070510000Medicaid
WV0044083000Medicaid