Basic Information
| Provider Information | |||||||||
| NPI: | 1366565152 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IVYCREEK OF ELMORE LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | RIVER REGION FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 41 CAMBRIDGE CT | ||||||||
| Address2: | |||||||||
| City: | WETUMPKA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 360931261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3345673309 | ||||||||
| FaxNumber: | 3345673361 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2007 | ||||||||
| LastUpdateDate: | 10/01/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRUCE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3345674311 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | IVYCREEK OF ELMORE LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305R00000X | 22736 | AL | N | Managed Care Organizations | Preferred Provider Organization | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 540003434 | 05 | AL | MEDICAID |