Provider Demographics
NPI:1205034428
Name:IVYCREEK OF ELMORE LLC
Entity Type:Organization
Organization Name:IVYCREEK OF ELMORE LLC
Other - Org Name:ELMORE COMMUNITY HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:BRUCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-567-4311
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:WETUMPKA
Mailing Address - State:AL
Mailing Address - Zip Code:36092-0003
Mailing Address - Country:US
Mailing Address - Phone:334-567-4311
Mailing Address - Fax:334-567-4312
Practice Address - Street 1:500 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WETUMPKA
Practice Address - State:AL
Practice Address - Zip Code:36092-1625
Practice Address - Country:US
Practice Address - Phone:334-567-4311
Practice Address - Fax:334-567-4312
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IVYCREEK OF ELMORE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-10
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALH2601146N00000X
146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, BasicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529905190Medicaid
AL01D680545OtherCLIA