Basic Information
| Provider Information | |||||||||
| NPI: | 1649599119 | ||||||||
| 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: | 4195220493 | ||||||||
| Practice Location | |||||||||
| Address1: | 770 BALGREEN DRIVE | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449062633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195226800 | ||||||||
| FaxNumber: | 4195226816 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2010 | ||||||||
| LastUpdateDate: | 02/25/2022 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | PEGGY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4195267880 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 3111957 | 05 | OH | MEDICAID |