MEDICARE: TRI STATE UROLOGIC SERVICES PSC 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	2085R0204X	Vascular & Interventional Radiology Physician
2	208800000X	Urology Physician

General Provider Information

NPI Number	:	1912729005
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRI STATE UROLOGIC SERVICES PSC INC

Provider Business Mailing Address
First Line	:	PO BOX 738291
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75373-8291
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4746 MONTGOMERY RD
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45212-2622
Country	:	US
Telephone Number	:	513-841-7400
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	JANIS RUTH OSBORNE
Credential	:
Telephone Number	:	513-841-7466

Provider Enumeration Date	:	10/29/2024
Last Update Date	:	10/29/2024

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