Provider Demographics
NPI:1790093029
Name:IVY CREEK OF ELMORE LLC
Entity Type:Organization
Organization Name:IVY CREEK OF ELMORE LLC
Other - Org Name:IVY CREEK OF ELMORE HOSPITALIST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:BRUCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-567-4311
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:WETUMPKA
Mailing Address - State:AL
Mailing Address - Zip Code:36092-0003
Mailing Address - Country:US
Mailing Address - Phone:334-567-4311
Mailing Address - Fax:334-567-4312
Practice Address - Street 1:500 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WETUMPKA
Practice Address - State:AL
Practice Address - Zip Code:36092-1625
Practice Address - Country:US
Practice Address - Phone:334-567-4311
Practice Address - Fax:334-567-4312
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IVY CREEK OF ELMORE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-21
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL122925Medicaid
AL01D0680545OtherCLIA