Provider Demographics
NPI:1558314039
Name:THREE RIVERS SURGICAL ASSOCIATES, LLC
Entity type:Organization
Organization Name:THREE RIVERS SURGICAL ASSOCIATES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MEO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-969-2990
Mailing Address - Street 1:P.O. BOX 10653
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46853
Mailing Address - Country:US
Mailing Address - Phone:260-969-1950
Mailing Address - Fax:260-918-2137
Practice Address - Street 1:2510 E DUPONT RD
Practice Address - Street 2:SUITE 210
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1600
Practice Address - Country:US
Practice Address - Phone:260-969-2990
Practice Address - Fax:260-969-2991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200536920AMedicaid
INDE1356OtherRAILROAD MEDICARE
INDE1356OtherRAILROAD MEDICARE