Healthcare Provider Details

I. General information

NPI: 1114927209
Provider Name (Legal Business Name): TRISTATE IMG (IMAGING MEDICAL GROUP) INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 08/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 DIXMYTH AVE
CINCINNATI OH
45220
US

IV. Provider business mailing address

PO BOX 42456
CINCINNATI OH
45242-0456
US

V. Phone/Fax

Practice location:
  • Phone: 513-965-8041
  • Fax: 513-965-8091
Mailing address:
  • Phone: 513-965-8041
  • Fax: 513-965-8091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: LYNN GRAY
Title or Position: CLIENT SERVICES MANAGER
Credential:
Phone: 513-965-8041