Basic Information
| Provider Information | |||||||||
| NPI: | 1225104417 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN RURAL HEALTH CARE CONSORTIUM, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | TOWN CREEK FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 970 | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356530970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563321631 | ||||||||
| FaxNumber: | 2563324600 | ||||||||
| Practice Location | |||||||||
| Address1: | 1841 AL HWY 20 | ||||||||
| Address2: | |||||||||
| City: | TOWN CREEK | ||||||||
| State: | AL | ||||||||
| PostalCode: | 35672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563321631 | ||||||||
| FaxNumber: | 2563324600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 03/16/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HALL | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2563321631 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QF0400X | AL | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 01200281 | 01 | AL | BLUE CROSS | OTHER | 630001001 | 05 | AL | MEDICAID |