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
1	261QD0000X	Dental Clinic/Center
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
3	261QM0850X	Adult Mental Health Clinic/Center
4	261QM0855X	Adolescent and Children Mental Health Clinic/Center
5	261QP1100X	Podiatric Clinic/Center
6	3336C0002X	Clinic Pharmacy
7	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1548916893
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	:

Provider Business Practice Location Address
First Line	:	31 E MAIN ST
Second Line	:
City	:	SHELBY
State	:	OH
Zip	:	44875-1262
Country	:	US
Telephone Number	:	419-522-6191
Fax Number	:

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

Provider Enumeration Date	:	02/25/2022
Last Update Date	:	10/29/2024

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