Healthcare Provider Details

I. General information

NPI: 1720137037
Provider Name (Legal Business Name): THREE RIVERS MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 06/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 W. MCLEAN ST.
ST. PAULS NC
28384
US

IV. Provider business mailing address

580 W MCLEAN ST.
ST. PAULS NC
28384
US

V. Phone/Fax

Practice location:
  • Phone: 910-865-3063
  • Fax: 918-653-5063
Mailing address:
  • Phone: 910-865-3063
  • Fax: 910-865-3503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number100548
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number9700722
License Number StateNC

VIII. Authorized Official

Name: RAJU B RAVAL
Title or Position: ADMINISTRATOR
Credential: D.O.
Phone: 910-484-5366