MEDICARE: TRI-STATE OB-GYN PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician

General Provider Information

NPI Number	:	1063510204
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRI-STATE OB-GYN PC

Provider Business Mailing Address
First Line	:	3003 HIGHWAY 95
Second Line	:	STE 31
City	:	BULLHEAD CITY
State	:	AZ
Zip	:	86442-7860
Country	:	US
Telephone Number	:	928-704-2229
Fax Number	:	928-704-2255

Provider Business Practice Location Address
First Line	:	3003 HIGHWAY 95
Second Line	:	STE 31
City	:	BULLHEAD CITY
State	:	AZ
Zip	:	86442-7860
Country	:	US
Telephone Number	:	928-704-2229
Fax Number	:	928-704-2255

Authorized Official
Title or Position	:	PRESIDENT
Name	:	THEODORE LONDON
Credential	:	MD
Telephone Number	:	928-704-2229

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	08/22/2020

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