Provider Demographics
NPI:1306286513
Name:THREE RIVERS RADIOLOGY, LLC
Entity type:Organization
Organization Name:THREE RIVERS RADIOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & TREASURER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAREY
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-467-9716
Mailing Address - Street 1:PO BOX 8712
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46898-8712
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6819 LIMA RD
Practice Address - Street 2:SUITE 200
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46818-1145
Practice Address - Country:US
Practice Address - Phone:260-407-6200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-02
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99057753A207L00000X, 2081P2900X, 2085B0100X, 2085D0003X, 2085N0700X, 2085R0202X, 2085U0001X, 208VP0014X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty
No2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic NeuroimagingGroup - Multi-Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty