Provider Demographics
NPI:1558609990
Name:THIRD STREET COMMUNITY CLINIC, INC
Entity Type:Organization
Organization Name:THIRD STREET COMMUNITY CLINIC, INC
Other - Org Name:THIRD STREET OB/GYN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:419-522-6191
Mailing Address - Street 1:600 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-2633
Mailing Address - Country:US
Mailing Address - Phone:419-522-6191
Mailing Address - Fax:419-526-4911
Practice Address - Street 1:770 BALGREEN DR
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-4106
Practice Address - Country:US
Practice Address - Phone:419-522-6800
Practice Address - Fax:419-522-6816
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THIRD STREET COMMUNITY CLINIC, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-01-18
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35096570207V00000X
OH35088484207V00000X
OH35075677A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty