1649442369 NPI number — RUSSELLVILLE PHYSICIAN PRACTICES LLC

Table of content: (NPI 1649442369)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649442369 NPI number — RUSSELLVILLE PHYSICIAN PRACTICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RUSSELLVILLE PHYSICIAN PRACTICES LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
AZALEA OBGYN
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649442369
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/06/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 270
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RUSSELLVILLE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35653-0270
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-331-3988
Provider Business Mailing Address Fax Number:
256-331-3987

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
523 GANDY ST NE
Provider Second Line Business Practice Location Address:
SUITE F
Provider Business Practice Location Address City Name:
RUSSELLVILLE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35653-1961
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-331-3988
Provider Business Practice Location Address Fax Number:
256-331-3987
Provider Enumeration Date:
04/02/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GRACEY
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
615-372-8500

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  27647 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PENDING , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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