Provider Demographics
NPI:1386626075
Name:THREE RIVERS HEALTH AUTHORITY
Entity Type:Organization
Organization Name:THREE RIVERS HEALTH AUTHORITY
Other - Org Name:THREE RIVERS HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-273-9601
Mailing Address - Street 1:701 S HEALTH PKWY
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:THREE RIVERS
Mailing Address - State:MI
Mailing Address - Zip Code:49093-8352
Mailing Address - Country:US
Mailing Address - Phone:269-278-1145
Mailing Address - Fax:269-273-9611
Practice Address - Street 1:701 S HEALTH PKWY
Practice Address - Street 2:MEDICAL STAFF OFFICE
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093-8352
Practice Address - Country:US
Practice Address - Phone:269-273-9789
Practice Address - Fax:269-273-9611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-17
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI750020282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N99470OtherMEDICARE - DIETICIAN GROUP
MI1556456-30Medicaid
MI5172151-40Medicaid
MI0N99470Medicare PIN
MI1556456-30Medicaid
MI0N99470OtherMEDICARE - DIETICIAN GROUP