1396720579 NPI number — THREE RIVERS HEALTH

Table of content: (NPI 1396720579)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396720579 NPI number — THREE RIVERS HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THREE RIVERS HEALTH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
THREE RIVERS HEALTH SCHIMNOSKI FAMILY PRACTICE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396720579
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
701 S HEALTH PKWY
Provider Second Line Business Mailing Address:
MEDICAL STAFF OFFICE
Provider Business Mailing Address City Name:
THREE RIVERS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49093-8352
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-273-9789
Provider Business Mailing Address Fax Number:
269-273-9611

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
711 S HEALTH PKWY
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
THREE RIVERS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49093-9387
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-278-1265
Provider Business Practice Location Address Fax Number:
269-273-2454
Provider Enumeration Date:
12/12/2005

Additional Information

Authorized Official

Authorized Official Last Name:
RUSSELL
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE MANAGEMENT
Authorized Official Telephone Number:
269-273-9601

Provider Taxonomy Codes

  • Taxonomy code: 207QA0505X , with the licence number:  750020 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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