Healthcare Provider Details

I. General information

NPI: 1083130751
Provider Name (Legal Business Name): TRI-STATE COLORECTAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2017
Last Update Date: 07/25/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 S KENMORE DR STE B
EVANSVILLE IN
47714-7513
US

IV. Provider business mailing address

950 S KENMORE DR STE B
EVANSVILLE IN
47714-7513
US

V. Phone/Fax

Practice location:
  • Phone: 812-301-8110
  • Fax: 812-401-4001
Mailing address:
  • Phone: 812-301-8110
  • Fax: 812-401-4001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DEANE L SMITH II
Title or Position: PARTNER
Credential:
Phone: 812-301-8110