Basic Information
| Provider Information | |||||||||
| NPI: | 1003834441 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RUSSELL COUNTY CLINIC CORP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LEBANON PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3600 | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242660200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2768890201 | ||||||||
| FaxNumber: | 2768890018 | ||||||||
| Practice Location | |||||||||
| Address1: | 640 OVERLOOK DRIVE | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2768890201 | ||||||||
| FaxNumber: | 2768890018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | GROUP VP | ||||||||
| AuthorizedOfficialTelephone: | 2868890201 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.