Provider Demographics
NPI:1396720579
Name:THREE RIVERS HEALTH
Entity type:Organization
Organization Name:THREE RIVERS HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-273-9601
Mailing Address - Street 1:701 S HEALTH PKWY
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:THREE RIVERS
Mailing Address - State:MI
Mailing Address - Zip Code:49093-8352
Mailing Address - Country:US
Mailing Address - Phone:269-273-9789
Mailing Address - Fax:269-273-9611
Practice Address - Street 1:711 S HEALTH PKWY
Practice Address - Street 2:SUITE 4
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093-9387
Practice Address - Country:US
Practice Address - Phone:269-278-1265
Practice Address - Fax:269-273-2454
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THREE RIVERS HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-12-12
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI750020207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G56008Medicare PIN