Provider Demographics
NPI:1154332963
Name:RUSSELLVILLE HOSPITAL, LLC
Entity Type:Organization
Organization Name:RUSSELLVILLE HOSPITAL, LLC
Other - Org Name:LAKELAND CARDIOLOGY & INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:GRACEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-8500
Mailing Address - Street 1:103 POWELL CT
Mailing Address - Street 2:STE. 200
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5079
Mailing Address - Country:US
Mailing Address - Phone:615-372-8500
Mailing Address - Fax:615-372-8572
Practice Address - Street 1:531 GANDY ST NE
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AL
Practice Address - Zip Code:35653-1965
Practice Address - Country:US
Practice Address - Phone:205-485-7280
Practice Address - Fax:205-485-7391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
J701Medicare ID - Type Unspecified