Provider Demographics
NPI:1649599119
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:
Authorized Official - Phone:419-526-7880
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:419-522-0493
Practice Address - Street 1:770 BALGREEN DRIVE
Practice Address - Street 2:SUITE 207
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-2633
Practice Address - Country:US
Practice Address - Phone:419-522-6800
Practice Address - Fax:419-522-6816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-24
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3111957Medicaid