Provider Demographics
NPI:1902906019
Name:TRI-STATE ALLERGY, INC
Entity Type:Organization
Organization Name:TRI-STATE ALLERGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:C
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-529-6100
Mailing Address - Street 1:1001 20TH STREET
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25703
Mailing Address - Country:US
Mailing Address - Phone:304-529-6100
Mailing Address - Fax:304-529-0229
Practice Address - Street 1:1001 20TH STREET
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25703
Practice Address - Country:US
Practice Address - Phone:304-529-6100
Practice Address - Fax:304-529-0229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0011693000Medicaid
KY659300083Medicaid
OHL0874442Medicaid
OHL0489556Medicaid
KY64694763Medicaid
OHL0968403Medicaid
WV0044083000Medicaid
WV0070510000Medicaid
KY64698772Medicaid
KY64698772Medicaid
KY64694763Medicaid
WVLY0725852Medicare PIN
WVTR9263351Medicare PIN
KY5184Medicare PIN
KY0518402Medicare PIN
WVA15124Medicare UPIN
WV0070510000Medicaid
WV0011693000Medicaid
KY659300083Medicaid
WV030004350Medicare PIN