Basic Information
| Provider Information | |||||||||
| NPI: | 1205034428 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IVYCREEK OF ELMORE LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | ELMORE COMMUNITY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 130 | ||||||||
| Address2: | |||||||||
| City: | WETUMPKA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 360920003 | ||||||||
| 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: | 07/10/2007 | ||||||||
| LastUpdateDate: | 04/05/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRUCE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3345674311 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | IVYCREEK OF ELMORE LLC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 146N00000X | H2601 | AL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Emergency Medical Service Providers | Emergency Medical Technician, Basic | 146N00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Emergency Medical Service Providers | Emergency Medical Technician, Basic |
ID Information
| ID | Type | State | Issuer | Description | 529905190 | 05 | AL | MEDICAID | 01D680545 | 01 | AL | CLIA | OTHER |