Basic Information
| Provider Information | |||||||||
| NPI: | 1144547712 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IVY CREEK OF ELMORE, LLC | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| OtherOrganizationName: | ANESTHESIA @ ELMORE COMM. HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | WETUMPKA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 360921625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3345674311 | ||||||||
| FaxNumber: | 3345674312 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | WETUMPKA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 360921625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3345674311 | ||||||||
| FaxNumber: | 3345674312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2010 | ||||||||
| LastUpdateDate: | 01/27/2012 | ||||||||
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| AuthorizedOfficialLastName: | BRUCE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3345674311 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | IVY CREEK OF ELMORE, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 367500000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.