Provider Demographics
NPI:1558460378
Name:THREE RIVERS MEDICAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:THREE RIVERS MEDICAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:BINOY
Authorized Official - Middle Name:
Authorized Official - Last Name:OUSEPH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-402-7446
Mailing Address - Street 1:2331 LADUE LANE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804
Mailing Address - Country:US
Mailing Address - Phone:260-402-7446
Mailing Address - Fax:260-435-7007
Practice Address - Street 1:7910 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4159
Practice Address - Country:US
Practice Address - Phone:260-402-7446
Practice Address - Fax:260-435-7007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052976A207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN247440Medicare PIN