Provider Demographics
NPI:1750457941
Name:SOUTHERN RURAL HEALTH CARE CONSORTIUM, INC.
Entity Type:Organization
Organization Name:SOUTHERN RURAL HEALTH CARE CONSORTIUM, INC.
Other - Org Name:RUSSELLVILLE FAMILY PRACTICE
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-332-1361
Mailing Address - Street 1:PO BOX 970
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35653-0970
Mailing Address - Country:US
Mailing Address - Phone:256-332-1631
Mailing Address - Fax:256-332-4600
Practice Address - Street 1:318 COFFEE AVENUE
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AL
Practice Address - Zip Code:35653
Practice Address - Country:US
Practice Address - Phone:256-332-1631
Practice Address - Fax:256-332-4600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QF0400X
AL261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL01-1907OtherMEDICARE #
AL630007001Medicaid
AL011907Medicare Oscar/Certification