Healthcare Provider Details

I. General information

NPI: 1689653016
Provider Name (Legal Business Name): TRI-STATE MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 07/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N 17TH ST
KEOKUK IA
52632-3452
US

IV. Provider business mailing address

400 N 17TH ST
KEOKUK IA
52632-3452
US

V. Phone/Fax

Practice location:
  • Phone: 319-524-5734
  • Fax: 319-524-5758
Mailing address:
  • Phone: 319-524-5734
  • Fax: 319-524-5758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: BRYN ASBURY
Title or Position: OFFICE MANAGER
Credential:
Phone: 319-526-8789