Provider Demographics
NPI:1659712594
Name:RUSSELLVILLE PHYSICIAN PRACTICES LLC
Entity Type:Organization
Organization Name:RUSSELLVILLE PHYSICIAN PRACTICES LLC
Other - Org Name:RUSSELLVILLE GENERAL SURGEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-565-1898
Mailing Address - Street 1:PO BOX 1216
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35653-1216
Mailing Address - Country:US
Mailing Address - Phone:256-332-1533
Mailing Address - Fax:
Practice Address - Street 1:15225 HIGHWAY 43
Practice Address - Street 2:SUITE I
Practice Address - City:RUSSELLVILLE
Practice Address - State:AL
Practice Address - Zip Code:35653-1999
Practice Address - Country:US
Practice Address - Phone:256-332-1533
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-08
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty