Provider Demographics
NPI:1003805870
Name:RUSSELLVILLE FAMILY CLINIC PA
Entity Type:Organization
Organization Name:RUSSELLVILLE FAMILY CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOY
Authorized Official - Middle Name:A
Authorized Official - Last Name:PIKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-968-7170
Mailing Address - Street 1:PO BOX 1648
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-1648
Mailing Address - Country:US
Mailing Address - Phone:479-968-7170
Mailing Address - Fax:479-968-7607
Practice Address - Street 1:108 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-3362
Practice Address - Country:US
Practice Address - Phone:479-968-7170
Practice Address - Fax:479-968-7607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-14
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR119926002Medicaid
AR8772887600OtherMEDICARE # ISSUED BY GOVERMENT FOR RAILROAD CLAIMS
AR119926002Medicaid