MEDICARE: TRI - STATE MEDICAL GROUP, 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	332900000X	Non-Pharmacy Dispensing Site	OS006001L	PA

General Provider Information

NPI Number	:	1720129943
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRI - STATE MEDICAL GROUP, INC.

Provider Business Mailing Address
First Line	:	5626 OBERLIN DR
Second Line	:	SUITE 110
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-1705
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	21 7TH ST
Second Line	:
City	:	MIDLAND
State	:	PA
Zip	:	15059-1452
Country	:	US
Telephone Number	:	724-643-4852
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	KENNY HEINE
Credential	:
Telephone Number	:	858-625-2990

Provider Enumeration Date	:	02/09/2007
Last Update Date	:	10/17/2012

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