Provider Demographics
NPI:1710049671
Name:THREE RIVERS MEDICAL INC.
Entity Type:Organization
Organization Name:THREE RIVERS MEDICAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MALONEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-935-1607
Mailing Address - Street 1:208 SUWANNEE AVE NW
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32008-3265
Mailing Address - Country:US
Mailing Address - Phone:386-935-1607
Mailing Address - Fax:386-935-1667
Practice Address - Street 1:208 SUWANNEE AVE NW
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:FL
Practice Address - Zip Code:32008-3265
Practice Address - Country:US
Practice Address - Phone:386-935-1607
Practice Address - Fax:386-935-1667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2934442363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL303822000Medicaid
FLE2683WMedicare ID - Type UnspecifiedPART B GROUP MEMBER
FLS82533Medicare UPIN
FLAA485Medicare ID - Type UnspecifiedPART B GROUP