Provider Demographics
NPI:1043582224
Name:THREE RIVERS HEALTH SYSTEM, INC
Entity Type:Organization
Organization Name:THREE RIVERS HEALTH SYSTEM, INC
Other - Org Name:THREE RIVERS HEALTH FAMILY, INTERNAL MEDICINE AND WOMENS SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-647-3460
Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:711 S HEALTH PARKWAY STE 1
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093-8354
Practice Address - Country:US
Practice Address - Phone:269-273-8557
Practice Address - Fax:269-279-6461
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THREE RIVERS HEALTH SYSTEM, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-02-02
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1043582224Medicaid