=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790019438
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRI-STATE MEDICAL GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2009
-----------------------------------------------------
Last Update Date | 09/29/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1030 BEANER HOLLOW ROAD BEAVER MEDICAL COMMONS
-----------------------------------------------------
City | BEAVER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-770-0410
-----------------------------------------------------
Fax | 724-770-0414
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1030 BEANER HOLLOW ROAD BEAVER MEDICAL COMMONS
-----------------------------------------------------
City | BEAVER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-770-0410
-----------------------------------------------------
Fax | 724-770-0414
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT & CEO
-----------------------------------------------------
Name | NORMAN F MITRY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 724-773-4776
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | MD432785
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------