Provider Demographics
NPI:1700250511
Name:THIRD STREET COMMUNITY CLINIC INC
Entity Type:Organization
Organization Name:THIRD STREET COMMUNITY CLINIC INC
Other - Org Name:SHELBY OB/GYN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:POLLICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-522-6191
Mailing Address - Street 1:199 W MAIN ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SHELBY
Mailing Address - State:OH
Mailing Address - Zip Code:44875-1490
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:199 W MAIN ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:SHELBY
Practice Address - State:OH
Practice Address - Zip Code:44875-1490
Practice Address - Country:US
Practice Address - Phone:419-525-6732
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THIRD STREET COMMUNITY CLINIC INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-11-17
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)