Basic Information
| Provider Information | |||||||||
| NPI: | 1558576116 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THIRD STREET COMMUNITY CLINIC, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THIRD STREET OB/GYN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449062633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195226191 | ||||||||
| FaxNumber: | 4195264911 | ||||||||
| Practice Location | |||||||||
| Address1: | 770 BALGREEN DR STE 207 | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449064106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195226800 | ||||||||
| FaxNumber: | 4195256723 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2007 | ||||||||
| LastUpdateDate: | 09/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | JEREMY | ||||||||
| AuthorizedOfficialFirstName: | THERESA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 4195226191 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 273R00000X | N | Hospital Units | Psychiatric Unit | 276400000X | N | Hospital Units | Rehabilitation, Substance Use Disorder Unit | 283Q00000X | N | Hospitals | Psychiatric Hospital | 261QD0000X | N | Ambulatory Health Care Facilities | Clinic/Center | Dental | 261QF0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QM0850X | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QB0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Birthing | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QP1100X | N | Ambulatory Health Care Facilities | Clinic/Center | Podiatric | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.