Provider Demographics
NPI:1053939074
Name:TRI-STATE SURGICAL CENTER, LLC
Entity type:Organization
Organization Name:TRI-STATE SURGICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING/CODING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HILDA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HOFFMASTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-263-5129
Mailing Address - Street 1:1006 TAVERN RD
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-2864
Mailing Address - Country:US
Mailing Address - Phone:304-267-0556
Mailing Address - Fax:304-267-1460
Practice Address - Street 1:1006 TAVERN RD
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-2864
Practice Address - Country:US
Practice Address - Phone:304-267-0556
Practice Address - Fax:304-267-1460
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRI-STATE SURGICAL CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-07-07
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV6905041000Medicaid