Organization
TRI-STATE MEDICAL GROUP INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BRYN ASBURY (OFFICE MANAGER)
(319) 526-8789
Entity
Organization
Contact information
Practice address
400 N 17TH ST, KEOKUK, IA 52632-3452
(319) 524-5734
(319) 524-5758
Mailing address
400 N 17TH ST, KEOKUK, IA 52632-3452
(319) 524-5734
(319) 524-5758
Taxonomy
Speciality
Code
Description
License number
State
2084P0804X
Child & Adolescent Psychiatry Physician
—
—
208600000X
Surgery Physician
—
—
208D00000X
General Practice Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0145888
—
IA
05
—
1689653016
—
IL
05
—
1689653016
—
MO
01
—
56343
WELLMARK BC/BS
IA
Enumeration date
01/13/2006
Last updated
07/12/2011
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