Provider Demographics
NPI:1366625923
Name:FAMILY MEDICINE OF RUSSELLVILLE INC
Entity Type:Organization
Organization Name:FAMILY MEDICINE OF RUSSELLVILLE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:ALBERT
Authorized Official - Last Name:GREGORIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-332-8969
Mailing Address - Street 1:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35653-0099
Mailing Address - Country:US
Mailing Address - Phone:256-332-8969
Mailing Address - Fax:256-332-8353
Practice Address - Street 1:605 GANDY ST NE
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AL
Practice Address - Zip Code:35653-1911
Practice Address - Country:US
Practice Address - Phone:256-332-8969
Practice Address - Fax:256-332-8353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529933001Medicaid
AL529933001Medicaid