Healthcare Provider Details

I. General information

NPI: 1275785057
Provider Name (Legal Business Name): TRI-STATE MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2008
Last Update Date: 10/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 AUTUMN ST SUITE 101
ALIQUIPPA PA
15001-1301
US

IV. Provider business mailing address

99 AUTUMN ST SUITE 101
ALIQUIPPA PA
15001-1301
US

V. Phone/Fax

Practice location:
  • Phone: 724-375-3100
  • Fax:
Mailing address:
  • Phone: 724-375-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: NORMAN MITRY
Title or Position: PRESIDENT & CEO
Credential:
Phone: 724-773-4776