Basic Information
| Provider Information | |||||||||
| NPI: | 1558609990 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| 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 | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449064106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195226800 | ||||||||
| FaxNumber: | 4195226816 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2013 | ||||||||
| LastUpdateDate: | 05/26/2022 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | PEGGY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4195226191 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THIRD STREET COMMUNITY CLINIC, INC | ||||||||
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| AuthorizedOfficialCredential: | CEO | ||||||||
| NPICertificationDate: | 05/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 35096570 | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.