Healthcare Provider Details

I. General information

NPI: 1710740576
Provider Name (Legal Business Name): TRI-STATE HEALTH, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2024
Last Update Date: 02/05/2024
Certification Date: 02/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2527 JACOB TOME MEMORIAL HWY
COLORA MD
21917-1258
US

IV. Provider business mailing address

107 N BRIDGE ST
ELKTON MD
21921-5326
US

V. Phone/Fax

Practice location:
  • Phone: 410-392-6408
  • Fax:
Mailing address:
  • Phone: 410-392-6408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MUHAMMED ARIF NIAZ
Title or Position: MANAGING MEMBER
Credential: MD
Phone: 410-392-6408