Healthcare Provider Details

I. General information

NPI: 1093180903
Provider Name (Legal Business Name): TRI-STATE TELEMED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2015
Last Update Date: 12/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

178 PRIVATE ROAD 19423
SOUTH POINT OH
45680-8831
US

IV. Provider business mailing address

620 PRIVATE ROAD 19423
SOUTH POINT OH
45680-9019
US

V. Phone/Fax

Practice location:
  • Phone: 304-208-5978
  • Fax:
Mailing address:
  • Phone: 304-208-5978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number48537
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1121101
License Number StateKY

VIII. Authorized Official

Name: DR. SHANNON MAXEY
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 304-208-5978