Provider Demographics
NPI:1881738995
Name:TRI STATE SURGERY PC
Entity type:Organization
Organization Name:TRI STATE SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ARDITH
Authorized Official - Middle Name:A
Authorized Official - Last Name:RYBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-334-9171
Mailing Address - Street 1:1112 S 113TH CT
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-1857
Mailing Address - Country:US
Mailing Address - Phone:402-334-9171
Mailing Address - Fax:402-895-5060
Practice Address - Street 1:1112 S 113TH CT
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-1857
Practice Address - Country:US
Practice Address - Phone:402-334-9171
Practice Address - Fax:402-895-5060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE19489208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE099931Medicare PIN
MOX400000Medicare PIN
IAI19934Medicare PIN