Healthcare Provider Details

I. General information

NPI: 1083807093
Provider Name (Legal Business Name): TRI STATE UROLOGIC SERVICES PSC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2007
Last Update Date: 01/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 WILSON CREEK RD SUITE 01
LAWRENCEBURG IN
47025-2506
US

IV. Provider business mailing address

2000 JOSEPH E SANKER BLVD
CINCINNATI OH
45212-1979
US

V. Phone/Fax

Practice location:
  • Phone: 859-363-2200
  • Fax: 859-363-2201
Mailing address:
  • Phone: 513-841-7400
  • Fax: 513-841-7402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: EARL L WALZ
Title or Position: CEO
Credential:
Phone: 513-841-7400