# TRI-STATE PEDIATRICS

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1013098904
- **Authorized official:** MRS. MICHELLE ELIZABETH SISLER (BILLING CLERK)
- **Authorized official phone:** (606) 836-0919

## Contact information

- **Practice address:** 900 SAINT CHRISTOPHER DR, BUILDING 4 SUITE 101, ASHLAND, KY 41101-7090
- **Practice address phone:** (606) 836-0919
- **Practice address fax:** (606) 836-2847
- **Mailing address:** 900 SAINT CHRISTOPHER DR, BUILDING 4 SUITE 101, ASHLAND, KY 41101-7090
- **Mailing address phone:** (606) 836-0919
- **Mailing address fax:** (606) 836-2847

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 174400000X | Specialist | 02639 | KY | Yes |
| 174400000X | Specialist | 25781 | KY | — |
| 174400000X | Specialist | 38597 | KY | — |

## Other

- **Enumeration date:** 10/18/2006
- **Last updated:** 08/22/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 02639 | KY LICENSE | KY |
| 05 | — | 0665310 | — | OH |
| 05 | — | 2271429 | — | OH |
| 01 | — | 25781 | KY LICENSE | KY |
| 01 | — | 38597 | KY LICENSE | KY |
| 05 | — | 64011059 | — | KY |
| 05 | — | 64066384 | — | KY |
| 05 | — | 64257819 | — | KY |