Healthcare Provider Details

I. General information

NPI: 1639331275
Provider Name (Legal Business Name): THREE RIVERS MEDICAL ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 01/27/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 TAYLOR ST STE 5K
COLUMBIA SC
29201-2952
US

IV. Provider business mailing address

7430 COLLEGE ST
IRMO SC
29063-2903
US

V. Phone/Fax

Practice location:
  • Phone: 839-200-7805
  • Fax: 803-891-7085
Mailing address:
  • Phone: 839-200-7810
  • Fax: 803-891-7085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN GOULD III
Title or Position: PRESIDENT
Credential: MD
Phone: 839-200-7810