Provider Demographics
NPI:1639331275
Name:THREE RIVERS MEDICAL ASSOCIATES, PA
Entity Type:Organization
Organization Name:THREE RIVERS MEDICAL ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOULD
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:839-200-7810
Mailing Address - Street 1:7430 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-2903
Mailing Address - Country:US
Mailing Address - Phone:839-200-7810
Mailing Address - Fax:803-891-7085
Practice Address - Street 1:1301 TAYLOR ST STE 5K
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2952
Practice Address - Country:US
Practice Address - Phone:839-200-7805
Practice Address - Fax:803-891-7085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-25
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1320Medicaid
SCGP1320Medicaid