Healthcare Provider Details

I. General information

NPI: 1649599119
Provider Name (Legal Business Name): THIRD STREET COMMUNITY CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2010
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 BALGREEN DRIVE SUITE 207
MANSFIELD OH
44906-2633
US

IV. Provider business mailing address

1404 PARK AVE W STE 2
MANSFIELD OH
44906-2633
US

V. Phone/Fax

Practice location:
  • Phone: 419-522-6800
  • Fax: 419-522-6816
Mailing address:
  • Phone: 419-522-6191
  • Fax: 419-522-0493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: PEGGY ANDERSON
Title or Position: CEO
Credential:
Phone: 419-526-7880