Provider Demographics
NPI:1720137037
Name:THREE RIVERS MEDICAL CENTER
Entity Type:Organization
Organization Name:THREE RIVERS MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RAJU
Authorized Official - Middle Name:B
Authorized Official - Last Name:RAVAL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:910-484-5366
Mailing Address - Street 1:580 W MCLEAN ST.
Mailing Address - Street 2:
Mailing Address - City:ST. PAULS
Mailing Address - State:NC
Mailing Address - Zip Code:28384
Mailing Address - Country:US
Mailing Address - Phone:910-865-3063
Mailing Address - Fax:910-865-3503
Practice Address - Street 1:580 W. MCLEAN ST.
Practice Address - Street 2:
Practice Address - City:ST. PAULS
Practice Address - State:NC
Practice Address - Zip Code:28384
Practice Address - Country:US
Practice Address - Phone:910-865-3063
Practice Address - Fax:918-653-5063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100548207Q00000X
207R00000X
NC9700722207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89011VUMedicaid
NC2344706Medicare ID - Type UnspecifiedMEDICARE
NC89011VUMedicaid