Healthcare Provider Details

I. General information

NPI: 1801993175
Provider Name (Legal Business Name): TRI STATE SURGICAL ASSOCIATES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 11/01/2023
Certification Date: 11/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

384 CRYSTAL RUN RD SUITE 201
MIDDLETOWN NY
10941-4013
US

IV. Provider business mailing address

384 CRYSTAL RUN RD SUITE 201
MIDDLETOWN NY
10941-4013
US

V. Phone/Fax

Practice location:
  • Phone: 845-692-8780
  • Fax: 845-692-3439
Mailing address:
  • Phone: 845-692-8780
  • Fax: 845-692-3439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number216778
License Number StateNY

VIII. Authorized Official

Name: GINA KOWAL
Title or Position: BILLING MANAGER
Credential:
Phone: 845-692-8780