Healthcare Provider Details

I. General information

NPI: 1609950476
Provider Name (Legal Business Name): TRISTATE INFECTIOUS DISEASE CONSULTANTS, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 LEXINGTON AVE STE 125
ASHLAND KY
41101-2873
US

IV. Provider business mailing address

PO BOX 1547
ASHLAND KY
41105-1547
US

V. Phone/Fax

Practice location:
  • Phone: 606-325-2721
  • Fax: 606-325-2416
Mailing address:
  • Phone: 606-325-2721
  • Fax: 606-325-2416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. CECILIA GAYNOR
Title or Position: OWNER
Credential: MD
Phone: 606-325-2721