Provider Demographics
NPI:1003834441
Name:RUSSELL COUNTY CLINIC CORP
Entity Type:Organization
Organization Name:RUSSELL COUNTY CLINIC CORP
Other - Org Name:LEBANON PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GROUP VP
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:286-889-0201
Mailing Address - Street 1:PO BOX 3600
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:VA
Mailing Address - Zip Code:24266-0200
Mailing Address - Country:US
Mailing Address - Phone:276-889-0201
Mailing Address - Fax:276-889-0018
Practice Address - Street 1:640 OVERLOOK DRIVE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:VA
Practice Address - Zip Code:24266
Practice Address - Country:US
Practice Address - Phone:276-889-0201
Practice Address - Fax:276-889-0018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06008Medicare ID - Type Unspecified