Healthcare Provider Details

I. General information

NPI: 1205825122
Provider Name (Legal Business Name): TRI-STATE PEDIATRIC OPHTHALMOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 12/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 N 5TH ST SUITE 201
MARTINS FERRY OH
43935-1582
US

IV. Provider business mailing address

222 N 5TH ST SUITE 201
MARTINS FERRY OH
43935-1582
US

V. Phone/Fax

Practice location:
  • Phone: 740-633-6671
  • Fax: 740-633-6679
Mailing address:
  • Phone: 740-633-6671
  • Fax: 740-633-6679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number20425
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number35-84204
License Number StateOH

VIII. Authorized Official

Name: DR. KENNETH M GAINER
Title or Position: OWNER
Credential: MD
Phone: 740-633-6671