Provider Demographics
NPI:1447291240
Name:TRI-STATE FAMILY MEDICINE, PSC
Entity type:Organization
Organization Name:TRI-STATE FAMILY MEDICINE, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ARASH
Authorized Official - Middle Name:DAEMI
Authorized Official - Last Name:KAYFAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:606-327-4445
Mailing Address - Street 1:941 29TH ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-3021
Mailing Address - Country:US
Mailing Address - Phone:606-327-4445
Mailing Address - Fax:
Practice Address - Street 1:941 29TH ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-3021
Practice Address - Country:US
Practice Address - Phone:606-327-4445
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02726207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000208077OtherBC/BS
OH2297492Medicaid
KY64041908Medicaid
KY000000208077OtherBC/BS
KY0264228Medicare ID - Type UnspecifiedGRAYSON
KY0632921Medicare ID - Type UnspecifiedFLATWOODS
H52021Medicare UPIN
KY0307624Medicare ID - Type UnspecifiedCATLETTSBURG
KY3400310Medicare ID - Type UnspecifiedOLIVE HILL
OH2297492Medicaid