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NPI Code Detail

MEDICARE: TRI-STATE TELEMED LLC

MEDICARE: TRI-STATE TELEMED LLC
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
1363L00000XNurse Practitioner1121101KY
2208D00000XGeneral Practice Physician48537KY

General Provider Information

NPI Number : 1093180903
Entity Type Code : Organization
Provider Name (Legal Business Name) : TRI-STATE TELEMED LLC
Provider Business Mailing Address
First Line : 620 PRIVATE ROAD 19423
Second Line :
City : SOUTH POINT
State : OH
Zip : 45680-9019
Country : US
Telephone Number : 304-208-5978
Fax Number :
Provider Business Practice Location Address
First Line : 178 PRIVATE ROAD 19423
Second Line :
City : SOUTH POINT
State : OH
Zip : 45680-8831
Country : US
Telephone Number : 304-208-5978
Fax Number :
Authorized Official
Title or Position : MEDICAL DIRECTOR
Name : DR. SHANNON MAXEY
Credential : M.D.
Telephone Number : 304-208-5978
Provider Enumeration Date : 12/02/2015
Last Update Date : 12/02/2015

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Directions to “TRI-STATE TELEMED LLC ” Practice Location

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