Provider Demographics
NPI:1982421889
Name:THREE RIVERS MEDICINE LLC
Entity type:Organization
Organization Name:THREE RIVERS MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SEBASTIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUECKERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-605-4052
Mailing Address - Street 1:170 DIELMAN RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63124-1705
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:456 NORTH NEW BALLAS ROAD
Practice Address - Street 2:SUITE 126
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-6812
Practice Address - Country:US
Practice Address - Phone:314-605-4052
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-23
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty