Healthcare Provider Details

I. General information

NPI: 1326275595
Provider Name (Legal Business Name): TRI-STATE MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 06/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ROUTE 18 WAL-MART SHOPPING PLAZA HERITAGE VALLEY CONVENIENT CARE-MONACA
MONACA PA
15061
US

IV. Provider business mailing address

1000 DUTCH RIDGE ROAD HERITAGE VALLEY BEAVER CREDENTIALING C-4
BEAVER PA
15009
US

V. Phone/Fax

Practice location:
  • Phone: 724-774-5175
  • Fax: 724-774-5175
Mailing address:
  • Phone: 724-773-4776
  • Fax: 724-773-4726

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
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

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