Provider Demographics
NPI:1396738944
Name:MAXWELL AFB AMBULATORY HEALTH CARE CENTER
Entity type:Organization
Organization Name:MAXWELL AFB AMBULATORY HEALTH CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY PRACTICE PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:TOMEKA
Authorized Official - Middle Name:DANIELLE
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-953-1307
Mailing Address - Street 1:375 ASHTON PARK DR
Mailing Address - Street 2:
Mailing Address - City:MILLBROOK
Mailing Address - State:AL
Mailing Address - Zip Code:36054
Mailing Address - Country:US
Mailing Address - Phone:334-290-0399
Mailing Address - Fax:
Practice Address - Street 1:300 S. TWINING STREET
Practice Address - Street 2:BLDG 760, FAMILY PRACTICE - YELLOW TEAM
Practice Address - City:MAXWELL AFB
Practice Address - State:AL
Practice Address - Zip Code:36112
Practice Address - Country:US
Practice Address - Phone:334-953-2234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL25934261QM1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient