Provider Demographics
NPI:1518932094
Name:TRI-STATE ORTHOPEDIC INSTITUTE, P.C.
Entity type:Organization
Organization Name:TRI-STATE ORTHOPEDIC INSTITUTE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:A
Authorized Official - Last Name:STAMPER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:928-758-1175
Mailing Address - Street 1:PO BOX 27340
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85061-7340
Mailing Address - Country:US
Mailing Address - Phone:602-943-9200
Mailing Address - Fax:602-216-3000
Practice Address - Street 1:2000 HIGHWAY 95
Practice Address - Street 2:SUITE 200
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-6050
Practice Address - Country:US
Practice Address - Phone:928-758-1175
Practice Address - Fax:928-758-5191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-20
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ385270Medicaid
AZ385270Medicaid
AZCE1658Medicare PIN
AZ0893840001Medicare NSC