Provider Demographics
NPI:1649370719
Name:TRI STATE MEDICAL CLINIC INC
Entity type:Organization
Organization Name:TRI STATE MEDICAL CLINIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:B
Authorized Official - Last Name:ROARK
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:606-242-3100
Mailing Address - Street 1:PO BOX 217
Mailing Address - Street 2:
Mailing Address - City:MIDDLESBORO
Mailing Address - State:KY
Mailing Address - Zip Code:40965-0217
Mailing Address - Country:US
Mailing Address - Phone:606-242-3100
Mailing Address - Fax:606-242-3984
Practice Address - Street 1:3503 CUMBERLAND AVE
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965-2611
Practice Address - Country:US
Practice Address - Phone:606-242-3100
Practice Address - Fax:606-242-3984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7564Medicare PIN