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	3336C0002X	Clinic Pharmacy
2	261QF0400X	Federally Qualified Health Center (FQHC)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336252519
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THIRD STREET COMMUNITY CLINIC, INC.

Provider Business Mailing Address
First Line	:	1404 PARK AVE W
Second Line	:	STE 2
City	:	MANSFIELD
State	:	OH
Zip	:	44906-2633
Country	:	US
Telephone Number	:	419-522-6191
Fax Number	:	419-526-7939

Provider Business Practice Location Address
First Line	:	600 W. THIRD STREET
Second Line	:
City	:	MANSFIELD
State	:	OH
Zip	:	44906-2633
Country	:	US
Telephone Number	:	419-522-6191
Fax Number	:	419-526-7939

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

Provider Enumeration Date	:	08/15/2006
Last Update Date	:	05/19/2026

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Directions to “THIRD STREET COMMUNITY CLINIC, INC. ” Practice Location

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