Basic Information
| Provider Information | |||||||||
| NPI: | 1386602332 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THREE RIVERS ENDOSCOPY CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 725 CHERRINGTON PARKWAY | ||||||||
| Address2: | STE 101 | ||||||||
| City: | MOON TOWNSHIP | ||||||||
| State: | PA | ||||||||
| PostalCode: | 151084305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4122621000 | ||||||||
| FaxNumber: | 4122624607 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 CHERRINGTON PARKWAY | ||||||||
| Address2: | STE 101 | ||||||||
| City: | MOON TOWNSHIP | ||||||||
| State: | PA | ||||||||
| PostalCode: | 151084305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4122621000 | ||||||||
| FaxNumber: | 4122624607 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2006 | ||||||||
| LastUpdateDate: | 02/09/2017 | ||||||||
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| AuthorizedOfficialLastName: | STINE | ||||||||
| AuthorizedOfficialFirstName: | LESTER | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4122621000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 391061 | PA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 001652309 | 05 | PA | MEDICAID |