=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275705048
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRI-STATE PAIN MANAGEMENT SERVICE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2008
-----------------------------------------------------
Last Update Date | 03/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4415 AICHOLTZ RD
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45245-1506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-341-7246
-----------------------------------------------------
Fax | 859-341-7867
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7655 5 MILE RD STE 117
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45230-4326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-624-7525
-----------------------------------------------------
Fax | 513-624-0578
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | JEWELL ASHLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 513-624-7525
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------