Provider Demographics
NPI:1467975581
Name:IVY CREEK OF ELMORE LLC
Entity Type:Organization
Organization Name:IVY CREEK OF ELMORE LLC
Other - Org Name:IVY CREEK INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LYNDA
Authorized Official - Middle Name:GAYLE
Authorized Official - Last Name:DOZIER-MCCORMICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-514-3848
Mailing Address - Street 1:807 JACKSON TRACE RD
Mailing Address - Street 2:
Mailing Address - City:WETUMPKA
Mailing Address - State:AL
Mailing Address - Zip Code:36092-1504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:807 JACKSON TRACE RD
Practice Address - Street 2:
Practice Address - City:WETUMPKA
Practice Address - State:AL
Practice Address - Zip Code:36092-1504
Practice Address - Country:US
Practice Address - Phone:334-358-3777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-20
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty