MEDICARE: THIRD STREET COMMUNITY CLINIC, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1104461805
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THIRD STREET COMMUNITY CLINIC, INC.

Provider Business Mailing Address
First Line	:	1404 PARK AVE W STE 2
Second Line	:
City	:	ONTARIO
State	:	OH
Zip	:	44906-2719
Country	:	US
Telephone Number	:	419-522-6191
Fax Number	:	419-525-6723

Provider Business Practice Location Address
First Line	:	309 ARTHUR ST
Second Line	:
City	:	ASHLAND
State	:	OH
Zip	:	44805-3206
Country	:	US
Telephone Number	:	567-217-7778
Fax Number	:	419-525-6723

Authorized Official
Title or Position	:	CEO
Name	:	PEGGY ANDERSON
Credential	:
Telephone Number	:	419-526-7880

Provider Enumeration Date	:	11/18/2019
Last Update Date	:	05/19/2026

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