Provider Demographics
NPI:1508840596
Name:THREE RIVERS HEALTH AUTHORITY
Entity Type:Organization
Organization Name:THREE RIVERS HEALTH AUTHORITY
Other - Org Name:THREE RIVERS HEALTH FAMILY CARE CENTREVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PRESIDENT
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:269-273-9789
Mailing Address - Fax:269-273-9611
Practice Address - Street 1:677 E MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:MI
Practice Address - Zip Code:49032-8525
Practice Address - Country:US
Practice Address - Phone:269-467-9011
Practice Address - Fax:269-467-9511
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THREE RIVERS HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-12-02
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI750020261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700G560080OtherBCBSM
MI238511Medicare ID - Type Unspecified