Provider Demographics
NPI:1760489256
Name:TRI-STATE MRI PTR
Entity type:Organization
Organization Name:TRI-STATE MRI PTR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ALICE
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-522-6674
Mailing Address - Street 1:PO BOX 494
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25709-0494
Mailing Address - Country:US
Mailing Address - Phone:304-522-6674
Mailing Address - Fax:304-522-4647
Practice Address - Street 1:1802 6TH AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25703-1519
Practice Address - Country:US
Practice Address - Phone:304-522-6674
Practice Address - Fax:304-522-4647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0036348000Medicaid
OH0682677Medicaid
WV0036348000Medicaid
WVID00271Medicare ID - Type UnspecifiedPALMETTO GBA
OH0682677Medicaid