Provider Demographics
NPI:1215219134
Name:RUSSELLVILLE PHYSICIANS LLC
Entity Type:Organization
Organization Name:RUSSELLVILLE PHYSICIANS LLC
Other - Org Name:RUSSELLVILLE CARDIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-332-8679
Mailing Address - Street 1:P.O. BOX 1216
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35653-1999
Mailing Address - Country:US
Mailing Address - Phone:256-331-5828
Mailing Address - Fax:256-331-5829
Practice Address - Street 1:15225 HIGHWAY 43
Practice Address - Street 2:SUITE B
Practice Address - City:RUSSELLVILLE
Practice Address - State:AL
Practice Address - Zip Code:35653-1999
Practice Address - Country:US
Practice Address - Phone:256-331-5828
Practice Address - Fax:256-331-5829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-16
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL31191207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL132621Medicaid
AL169984Medicaid
J747Medicare PIN
AL169984Medicaid