Provider Demographics
NPI:1528377983
Name:RUSSELLVILLE PHYSICIAN PRACTICES LLC
Entity Type:Organization
Organization Name:RUSSELLVILLE PHYSICIAN PRACTICES LLC
Other - Org Name:BANKHEAD GENERAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:BIVACCA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-8500
Mailing Address - Street 1:523 GANDY ST NE
Mailing Address - Street 2:SUITE E
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35653-1961
Mailing Address - Country:US
Mailing Address - Phone:256-331-1449
Mailing Address - Fax:256-331-5182
Practice Address - Street 1:523 GANDY ST NE
Practice Address - Street 2:SUITE E
Practice Address - City:RUSSELLVILLE
Practice Address - State:AL
Practice Address - Zip Code:35653-1961
Practice Address - Country:US
Practice Address - Phone:256-331-1449
Practice Address - Fax:256-331-5182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL17151208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALPENDINGMedicaid
ALPENDINGMedicare PIN