1245668383 NPI number — THREE RIVERS HEALTH SYSTEM, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245668383 NPI number — THREE RIVERS HEALTH SYSTEM, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THREE RIVERS HEALTH SYSTEM, INC
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:
Provider Other Organization Name Type Code:
6
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:
1245668383
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3245 HEALTH DR STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRANGER
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46530-1380
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARCELLUS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49067
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-646-0443
Provider Business Practice Location Address Fax Number:
269-646-0447
Provider Enumeration Date:
10/29/2013

Additional Information

Authorized Official

Authorized Official Last Name:
COSTELLO
Authorized Official First Name:
JEFFERY
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
574-647-3460

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1245668383 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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