Healthcare Provider Details

I. General information

NPI: 1215106323
Provider Name (Legal Business Name): TRI-STATE PAIN INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2008
Last Update Date: 09/11/2020
Certification Date: 09/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2374 VILLAGE COMMON DR SUITE 100
ERIE PA
16506-7201
US

IV. Provider business mailing address

2374 VILLAGE COMMON DR SUITE 100
ERIE PA
16506-7201
US

V. Phone/Fax

Practice location:
  • Phone: 814-833-7246
  • Fax: 814-833-1147
Mailing address:
  • Phone: 814-833-7246
  • Fax: 814-833-1147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberMD045797L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberMD045797L
License Number StatePA

VIII. Authorized Official

Name: JOSEPH A THOMAS
Title or Position: SUPERVISOR
Credential:
Phone: 814-833-1147