Basic Information
| Provider Information | |||||||||
| NPI: | 1477979672 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RMCCA CLINIC A, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | REGIONAL MEDICAL CENTER CLINICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 300 N COLLEGE STREET | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3343822681 | ||||||||
| FaxNumber: | 3343839884 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 N COLLEGE STREET | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3343822681 | ||||||||
| FaxNumber: | 3343839884 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2014 | ||||||||
| LastUpdateDate: | 03/20/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SALTER | ||||||||
| AuthorizedOfficialFirstName: | AMANDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3343715025 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE HEALTH CARE AUTHORITY OF THE CITY | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 170603 | 05 | AL | MEDICAID |