Provider Demographics
NPI:1992197925
Name:THREE RIVERS HEALTH SYSTEM, INC
Entity Type:Organization
Organization Name:THREE RIVERS HEALTH SYSTEM, INC
Other - Org Name:KALAMAZOO FOOT & ANKLE SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-647-3460
Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7971 MOORSBRIDGE RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4075
Practice Address - Country:US
Practice Address - Phone:269-323-2094
Practice Address - Fax:269-323-2095
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THREE RIVERS HEALTH SYSTEM, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-02-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1992197925Medicaid