Provider Demographics
NPI:1770565954
Name:TRI-STATE PAIN MANAGEMENT SERVICE INC
Entity type:Organization
Organization Name:TRI-STATE PAIN MANAGEMENT SERVICE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEWELL
Authorized Official - Middle Name:
Authorized Official - Last Name:ASHLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-624-7525
Mailing Address - Street 1:7655 5 MILE RD STE 117
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45230-4326
Mailing Address - Country:US
Mailing Address - Phone:513-624-7525
Mailing Address - Fax:513-624-0578
Practice Address - Street 1:7655 FIVE MILE RD
Practice Address - Street 2:STE 117
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45230
Practice Address - Country:US
Practice Address - Phone:859-341-7246
Practice Address - Fax:513-624-0578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-15
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
728014OtherBUCKEYE
KY65944233Medicaid
OH2044773Medicaid
000000388145OtherANTHEM
IN200529320AMedicaid
5124498OtherCIGNA
5124498OtherCIGNA
=========OtherHEALTHLAB GROUP #
=========OtherHEALTHNET
KY65944233Medicaid