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General NPI Number Information
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NPI Number | 1366849283
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Entity Type | Organization
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Legal Business Name | TRI STATE NEUROLOGY, PLLC
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Dates
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Enumeration Date | 11/20/2014
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Last Update Date | 11/21/2014
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Provider Practice Location Address
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Address Line | 1450 DIEDERICH BLVD
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City | RUSSELL
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State | KY
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Zip | 41169-1719
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Country | US
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Telephone | 606-836-5565
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Fax | 606-836-5567
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Provider Business Mailing Address
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Address Line | 1450 DIEDERICH BLVD
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City | RUSSELL
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State | KY
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Zip | 41169-1719
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Country | US
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Telephone | 606-836-5565
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Fax | 606-836-5567
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Authorized Official
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Title or Position | OWNER
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Name | DR. STEVEN DOUGLAS DEITCH
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Credential | M.D.
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Telephone | 606-836-5565
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | 26535
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License Number State | KY
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