Basic Information
| Provider Information | |||||||||
| NPI: | 1245372168 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IVY CREEK OF BUTLER, LLC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | REGIONAL MEDICAL CENTER CLINICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 N COLLEGE ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3343822681 | ||||||||
| FaxNumber: | 3343839884 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 CHURCH STREET | ||||||||
| Address2: | |||||||||
| City: | GEORGIANA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3343762291 | ||||||||
| FaxNumber: | 3343763655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 06/25/2019 | ||||||||
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| AuthorizedOfficialLastName: | WILCOX | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | GLENN | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3343832423 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPA (INACTIVE) | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 11769 | AL | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 540003424 | 05 | AL | MEDICAID |