Basic Information
Provider Information | |||||||||
NPI: | 1073689261 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTHERN RURAL HEALTH CARE CONSORTIUM INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CHILDREN'S HEALTH OF DECATUR | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 508 SAINT CLAIR ST SE | ||||||||
Address2: |   | ||||||||
City: | RUSSELLVILLE | ||||||||
State: | AL | ||||||||
PostalCode: | 356532720 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2563321631 | ||||||||
FaxNumber: | 2563324600 | ||||||||
Practice Location | |||||||||
Address1: | 1304 13TH AVENUE S.E. | ||||||||
Address2: | SUITE A | ||||||||
City: | DECATUR | ||||||||
State: | AL | ||||||||
PostalCode: | 356010000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2563530178 | ||||||||
FaxNumber: | 2563536723 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/28/2006 | ||||||||
LastUpdateDate: | 03/16/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HALL | ||||||||
AuthorizedOfficialFirstName: | KATHY | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 2563321631 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   | AL | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 630002001 | 05 | AL |   | MEDICAID | 01-1898 | 01 | AL | MEDICARE # | OTHER |