Provider Demographics
NPI:1750407474
Name:TRI-STATE PODIATRIC MEDICAL SERVICES PSC
Entity type:Organization
Organization Name:TRI-STATE PODIATRIC MEDICAL SERVICES PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:270-830-5522
Mailing Address - Street 1:PO BOX 1593
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42419-1593
Mailing Address - Country:US
Mailing Address - Phone:270-830-6522
Mailing Address - Fax:
Practice Address - Street 1:411 LETCHER ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-4245
Practice Address - Country:US
Practice Address - Phone:270-830-6522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYCK6362OtherRAILROAD MEDICARE
ININ3186Medicare PIN
KY7198Medicare PIN
KY4811770001Medicare NSC