MEDICARE: TRI STATE PRIMARY CARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225016298
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRI STATE PRIMARY CARE LLC

Provider Business Mailing Address
First Line	:	PO BOX 633359
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45263-3359
Country	:	US
Telephone Number	:	513-557-3330
Fax Number	:	513-557-3199

Provider Business Practice Location Address
First Line	:	4010 N BEND RD
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45211-3500
Country	:	US
Telephone Number	:	513-598-3500
Fax Number	:	513-598-3508

Authorized Official
Title or Position	:	BUSINESS MANAGER PHYSICIAN PRACTICE
Name	:	KELLY BERNENS
Credential	:
Telephone Number	:	513-559-2891

Provider Enumeration Date	:	01/09/2006
Last Update Date	:	09/04/2008

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Directions to “TRI STATE PRIMARY CARE LLC ” Practice Location

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