Provider Demographics
NPI:1750495156
Name:FLORENCE OB/GYN GROUP, PC
Entity Type:Organization
Organization Name:FLORENCE OB/GYN GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MYRA
Authorized Official - Middle Name:H
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-740-0690
Mailing Address - Street 1:156 TITAN DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630-1197
Mailing Address - Country:US
Mailing Address - Phone:256-740-0690
Mailing Address - Fax:256-740-0694
Practice Address - Street 1:156 TITAN DR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-1197
Practice Address - Country:US
Practice Address - Phone:256-740-0690
Practice Address - Fax:256-740-0694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529401030Medicaid
G742Medicare PIN