Basic Information
Provider Information | |||||||||
NPI: | 1720407554 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THIRD STREET COMMUNITY CLINIC, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MANSFIELD FAMILY HEALTH 2 | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 600 W 3RD ST | ||||||||
Address2: |   | ||||||||
City: | MANSFIELD | ||||||||
State: | OH | ||||||||
PostalCode: | 449062633 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4195226191 | ||||||||
FaxNumber: | 4195256723 | ||||||||
Practice Location | |||||||||
Address1: | 270 STERKEL BLVD | ||||||||
Address2: | SUITE A | ||||||||
City: | MANSFIELD | ||||||||
State: | OH | ||||||||
PostalCode: | 449071508 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4197751141 | ||||||||
FaxNumber: | 4195256723 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/09/2014 | ||||||||
LastUpdateDate: | 02/25/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ANDERSON | ||||||||
AuthorizedOfficialFirstName: | PEGGY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 4195267880 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/25/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X |   |   | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.