Provider Demographics
NPI:1902073554
Name:TRI-STATE BEHAVIORAL HEALTH LLC
Entity Type:Organization
Organization Name:TRI-STATE BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANJUM
Authorized Official - Middle Name:SHEHZAD
Authorized Official - Last Name:ASHRAF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-962-2353
Mailing Address - Street 1:1900 WATERS RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-8084
Mailing Address - Country:US
Mailing Address - Phone:812-962-2353
Mailing Address - Fax:812-962-0915
Practice Address - Street 1:1116 MILLIS AVE
Practice Address - Street 2:ST. MARY'S WARRICK
Practice Address - City:BOONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47601
Practice Address - Country:US
Practice Address - Phone:812-962-2353
Practice Address - Fax:812-962-0915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01048619A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200478750 AMedicaid
IN234630OtherMEDICARE - ID
IN234630OtherMEDICARE - ID