Provider Demographics
NPI:1649442369
Name:RUSSELLVILLE PHYSICIAN PRACTICES LLC
Entity type:Organization
Organization Name:RUSSELLVILLE PHYSICIAN PRACTICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:GRACEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-8500
Mailing Address - Street 1:PO BOX 270
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35653-0270
Mailing Address - Country:US
Mailing Address - Phone:256-331-3988
Mailing Address - Fax:256-331-3987
Practice Address - Street 1:523 GANDY ST NE
Practice Address - Street 2:SUITE F
Practice Address - City:RUSSELLVILLE
Practice Address - State:AL
Practice Address - Zip Code:35653-1961
Practice Address - Country:US
Practice Address - Phone:256-331-3988
Practice Address - Fax:256-331-3987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL27647207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALPENDINGMedicaid
ALPENDINGMedicaid