Provider Demographics
NPI:1073689261
Name:SOUTHERN RURAL HEALTH CARE CONSORTIUM INC.
Entity Type:Organization
Organization Name:SOUTHERN RURAL HEALTH CARE CONSORTIUM INC.
Other - Org Name:CHILDREN'S HEALTH OF DECATUR
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-332-1631
Mailing Address - Street 1:508 SAINT CLAIR ST SE
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35653-2720
Mailing Address - Country:US
Mailing Address - Phone:256-332-1631
Mailing Address - Fax:256-332-4600
Practice Address - Street 1:1304 13TH AVENUE S.E.
Practice Address - Street 2:SUITE A
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-0000
Practice Address - Country:US
Practice Address - Phone:256-353-0178
Practice Address - Fax:256-353-6723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL630002001Medicaid
AL01-1898OtherMEDICARE #
AL01-1898OtherMEDICARE #