1225104417 NPI number — SOUTHERN RURAL HEALTH CARE CONSORTIUM, INC.

Table of content: (NPI 1225104417)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225104417 NPI number — SOUTHERN RURAL HEALTH CARE CONSORTIUM, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN RURAL HEALTH CARE CONSORTIUM, INC.
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:
TOWN CREEK FAMILY PRACTICE
Provider Other Organization Name Type Code:
5
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:
1225104417
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 970
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:
35653-0970
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-332-1631
Provider Business Mailing Address Fax Number:
256-332-4600

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1841 AL HWY 20
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOWN CREEK
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35672
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-332-1631
Provider Business Practice Location Address Fax Number:
256-332-4600
Provider Enumeration Date:
11/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HALL
Authorized Official First Name:
KATHY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
256-332-1631

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X , 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: 01200281 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 630001001 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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