Basic Information
| Provider Information | |||||||||
| NPI: | 1184679938 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FORT PAYNE RHC CORP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DEKALB CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4000 MERIDIAN BLVD | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370676325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154657585 | ||||||||
| FaxNumber: | 6154653007 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 MEDICAL CENTER DR SW | ||||||||
| Address2: | |||||||||
| City: | FORT PAYNE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 359683421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2569972820 | ||||||||
| FaxNumber: | 2569972890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 09/11/2012 | ||||||||
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| AuthorizedOfficialLastName: | PEOPLES | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6154657585 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FORT PAYNE RHC CORP | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 261QR1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 541003856 | 05 | AL | MEDICAID | 529929140 | 05 | AL | MEDICAID |