Healthcare Provider Details

I. General information

NPI: 1396720579
Provider Name (Legal Business Name): THREE RIVERS HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2005
Last Update Date: 01/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 S HEALTH PKWY SUITE 4
THREE RIVERS MI
49093-9387
US

IV. Provider business mailing address

701 S HEALTH PKWY MEDICAL STAFF OFFICE
THREE RIVERS MI
49093-8352
US

V. Phone/Fax

Practice location:
  • Phone: 269-278-1265
  • Fax: 269-273-2454
Mailing address:
  • Phone: 269-273-9789
  • Fax: 269-273-9611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number750020
License Number StateMI

VIII. Authorized Official

Name: WILLIAM RUSSELL
Title or Position: PRACTICE MANAGEMENT
Credential:
Phone: 269-273-9601