Basic Information
Provider Information | |||||||||
NPI: | 1215219134 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RUSSELLVILLE PHYSICIANS LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | RUSSELLVILLE CARDIOLOGY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | P.O. BOX 1216 | ||||||||
Address2: |   | ||||||||
City: | RUSSELLVILLE | ||||||||
State: | AL | ||||||||
PostalCode: | 356531999 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2563315828 | ||||||||
FaxNumber: | 2563315829 | ||||||||
Practice Location | |||||||||
Address1: | 15225 HIGHWAY 43 | ||||||||
Address2: | SUITE B | ||||||||
City: | RUSSELLVILLE | ||||||||
State: | AL | ||||||||
PostalCode: | 356531999 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2563315828 | ||||||||
FaxNumber: | 2563315829 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/16/2011 | ||||||||
LastUpdateDate: | 06/25/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STEWART | ||||||||
AuthorizedOfficialFirstName: | CHRISTINE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2563328679 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 31191 | AL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 132621 | 05 | AL |   | MEDICAID | 169984 | 05 | AL |   | MEDICAID |