1386626075 NPI number — THREE RIVERS HEALTH AUTHORITY

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 1386626075 NPI number — THREE RIVERS HEALTH AUTHORITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THREE RIVERS HEALTH AUTHORITY
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:
1386626075
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/05/2011
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:
269-278-1145
Provider Business Mailing Address Fax Number:
269-273-9611

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 S HEALTH PKWY
Provider Second Line Business Practice Location Address:
MEDICAL STAFF OFFICE
Provider Business Practice Location Address City Name:
THREE RIVERS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49093-8352
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-273-9789
Provider Business Practice Location Address Fax Number:
269-273-9611
Provider Enumeration Date:
11/17/2005

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , 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)

  • Identifier: 0N99470 . This is a "MEDICARE - DIETICIAN GROUP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1556456-30 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5172151-40 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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