Provider Demographics
NPI:1912982554
Name:THREE RIVERS HEALTH
Entity Type:Organization
Organization Name:THREE RIVERS HEALTH
Other - Org Name:THREE RIVERS HEALTH SURGICAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
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:269-278-1145
Mailing Address - Street 1:711 S HEALTH PKWY
Mailing Address - Street 2:SUITE L-7
Mailing Address - City:THREE RIVERS
Mailing Address - State:MI
Mailing Address - Zip Code:49093-9387
Mailing Address - Country:US
Mailing Address - Phone:269-273-9789
Mailing Address - Fax:269-273-9611
Practice Address - Street 1:715 S HEALTH PKWY
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093-8352
Practice Address - Country:US
Practice Address - Phone:269-273-8471
Practice Address - Fax:269-273-9680
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THREE RIVERS HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-12-07
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI750020207X00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G56008Medicare PIN