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	208600000X	Surgery Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1851543607
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRI-STATE MEDICAL GROUP, INC

Provider Business Mailing Address
First Line	:	1520 3RD AVE
Second Line	:
City	:	NEW BRIGHTON
State	:	PA
Zip	:	15066-2204
Country	:	US
Telephone Number	:	724-843-3800
Fax Number	:

Provider Business Practice Location Address
First Line	:	1520 3RD AVE
Second Line	:
City	:	NEW BRIGHTON
State	:	PA
Zip	:	15066-2204
Country	:	US
Telephone Number	:	724-843-3800
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT & CEO
Name	:	NORMAN F. MITRY
Credential	:
Telephone Number	:	724-773-4776

Provider Enumeration Date	:	10/10/2008
Last Update Date	:	10/10/2008

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Directions to “TRI-STATE MEDICAL GROUP, INC ” Practice Location

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