Healthcare Provider Details

I. General information

NPI: 1427368547
Provider Name (Legal Business Name): THREE RIVERS HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2010
Last Update Date: 10/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

633 S ERIE ST
THREE RIVERS MI
49093-2073
US

IV. Provider business mailing address

633 S ERIE ST
THREE RIVERS MI
49093-2073
US

V. Phone/Fax

Practice location:
  • Phone: 269-278-1829
  • Fax: 269-279-9080
Mailing address:
  • Phone: 269-278-1829
  • Fax: 269-279-9080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM RUSSELL
Title or Position: CEO/PRESIDENT
Credential:
Phone: 269-273-9701