Healthcare Provider Details

I. General information

NPI: 1942669296
Provider Name (Legal Business Name): THREE RIVERS HEALTH SYSTEM, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2016
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3850 GLENKERRY CT
PORTAGE MI
49024-0700
US

IV. Provider business mailing address

3245 HEALTH DR STE 100
GRANGER IN
46530-1380
US

V. Phone/Fax

Practice location:
  • Phone: 269-327-7200
  • Fax: 269-327-9272
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JEFFERY COSTELLO
Title or Position: CFO
Credential:
Phone: 574-647-3460