=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699723775
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRI-STATE FAMILY PRACTICE LLP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2006
-----------------------------------------------------
Last Update Date | 06/27/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1500 DELHI ST SUITE 4100
-----------------------------------------------------
City | DUBUQUE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52001-6358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-557-5900
-----------------------------------------------------
Fax | 563-557-5905
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1500 DELHI ST SUITE 4100
-----------------------------------------------------
City | DUBUQUE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52001-6358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-557-5900
-----------------------------------------------------
Fax | 563-557-5905
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MS. BARBARA A TLAMKA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 563-557-5900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 173000000X
-----------------------------------------------------
Taxonomy Name | Legal Medicine
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------