MEDICARE: TRI-STATE PAIN MANAGEMENT SERVICE INC

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	363L00000X	Nurse Practitioner
2	208VP0014X	Interventional Pain Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	284941995017	OTHER	MEDICAL MUTUAL
3	5124498	OTHER	CIGNA
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	728014	OTHER	BUCKEYE
6	610168000	OTHER	FEDERAL WORKERS COMP
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275705048
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRI-STATE PAIN MANAGEMENT SERVICE INC

Provider Business Mailing Address
First Line	:	7655 5 MILE RD STE 117
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45230-4326
Country	:	US
Telephone Number	:	513-624-7525
Fax Number	:	513-624-0578

Provider Business Practice Location Address
First Line	:	4415 AICHOLTZ RD
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45245-1506
Country	:	US
Telephone Number	:	859-341-7246
Fax Number	:	859-341-7867

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	JEWELL ASHLEY
Credential	:
Telephone Number	:	513-624-7525

Provider Enumeration Date	:	04/01/2008
Last Update Date	:	03/24/2020

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Directions to “TRI-STATE PAIN MANAGEMENT SERVICE INC ” Practice Location

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