Provider Demographics
NPI:1053359430
Name:TRI STATE ANESTHESIA ASSOCIATES PLC
Entity type:Organization
Organization Name:TRI STATE ANESTHESIA ASSOCIATES PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GROUP PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:HERMAN
Authorized Official - Middle Name:V
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-763-2273
Mailing Address - Street 1:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:2735 SILVER CREEK RD
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-7924
Practice Address - Country:US
Practice Address - Phone:928-763-2273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100504306Medicaid
AZ100504306Medicaid
CAXGG007530Medicaid
AZ100504306Medicaid
NV100504306Medicaid