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General NPI Number Information
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NPI Number | 1093180903
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Entity Type | Organization
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Legal Business Name | TRI-STATE TELEMED LLC
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Dates
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Enumeration Date | 12/02/2015
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Last Update Date | 12/02/2015
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Provider Practice Location Address
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Address Line | 178 PRIVATE ROAD 19423
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City | SOUTH POINT
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State | OH
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Zip | 45680-8831
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Country | US
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Telephone | 304-208-5978
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Fax |
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Provider Business Mailing Address
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Address Line | 620 PRIVATE ROAD 19423
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City | SOUTH POINT
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State | OH
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Zip | 45680-9019
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Country | US
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Telephone | 304-208-5978
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. SHANNON MAXEY
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Credential | M.D.
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Telephone | 304-208-5978
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 1121101
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 48537
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License Number State | KY
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