Provider Demographics
NPI:1689956500
Name:RUSSELLVILLE PHYSICIAN PRACTICES LLC
Entity Type:Organization
Organization Name:RUSSELLVILLE PHYSICIAN PRACTICES LLC
Other - Org Name:NORTH ALABAMA INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JESS
Authorized Official - Middle Name:N
Authorized Official - Last Name:JUDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-8500
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:256-331-1449
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:256-331-1449
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:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL31115207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL132812Medicaid
AL132812Medicaid