Healthcare Provider Details

I. General information

NPI: 1831146505
Provider Name (Legal Business Name): TRI STATE GYNECOLOGY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 10/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

690 STATE AVE
BEAVER PA
15009-9501
US

IV. Provider business mailing address

2 PEARTREE WAY
BEAVER PA
15009-1954
US

V. Phone/Fax

Practice location:
  • Phone: 724-774-4546
  • Fax: 724-774-9007
Mailing address:
  • Phone: 724-728-4171
  • Fax: 724-728-2019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. NORMAN F MITRY
Title or Position: PRESIDENT AND CEO
Credential:
Phone: 724-773-4779