Healthcare Provider Details

I. General information

NPI: 1508165994
Provider Name (Legal Business Name): TRI RIVERS SURGICAL ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2011
Last Update Date: 03/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 INNOVATION DRIVE SUITE 104D
SLIPPERY ROCK PA
16057
US

IV. Provider business mailing address

9104 BABCOCK BLVD SUITE 2120
PITTSBURGH PA
15237-5818
US

V. Phone/Fax

Practice location:
  • Phone: 866-874-7483
  • Fax: 412-367-7079
Mailing address:
  • Phone: 412-367-0600
  • Fax: 412-367-7079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. D. KELLY AGNEW
Title or Position: PRESIDENT
Credential: M.D.
Phone: 412-367-0600