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General NPI Number Information
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NPI Number | 1205825122
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Entity Type | Organization
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Legal Business Name | TRI-STATE PEDIATRIC OPHTHALMOLOGY, LLC
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Dates
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Enumeration Date | 10/14/2005
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Last Update Date | 12/27/2007
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Provider Practice Location Address
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Address Line | 222 N 5TH ST SUITE 201
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City | MARTINS FERRY
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State | OH
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Zip | 43935-1582
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Country | US
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Telephone | 740-633-6671
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Fax | 740-633-6679
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Provider Business Mailing Address
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Address Line | 222 N 5TH ST SUITE 201
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City | MARTINS FERRY
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State | OH
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Zip | 43935-1582
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Country | US
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Telephone | 740-633-6671
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Fax | 740-633-6679
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Authorized Official
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Title or Position | OWNER
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Name | DR. KENNETH M GAINER
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Credential | MD
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Telephone | 740-633-6671
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 20425
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License Number State | WV
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Taxonomy #2
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 35-84204
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License Number State | OH
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