Provider Demographics
NPI:1164412243
Name:RUSSELLVILLE GYNECOLOGY CLINIC
Entity Type:Organization
Organization Name:RUSSELLVILLE GYNECOLOGY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:BATTLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-968-7909
Mailing Address - Street 1:914 W B ST
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-3502
Mailing Address - Country:US
Mailing Address - Phone:479-968-7909
Mailing Address - Fax:479-968-6908
Practice Address - Street 1:914 W B ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-3502
Practice Address - Country:US
Practice Address - Phone:479-968-7909
Practice Address - Fax:479-968-6908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4687207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR13403000000OtherQUALCHOICE NUMBER
AR7420060OtherUNITED HEALTHCARE NUMBER
AR0004567368OtherAETNA NUMBER
AR7420060OtherUNITED HEALTHCARE NUMBER
ARD04342Medicare UPIN