Basic Information
Provider Information | |||||||||
NPI: | 1528255718 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTHERN RURAL HEALTH CARE CONSORTIUM | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 104 PHYSICIANS DRIVE | ||||||||
Address2: | SUITE B | ||||||||
City: | MUSCLE SHOALS | ||||||||
State: | AL | ||||||||
PostalCode: | 356610000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2563813308 | ||||||||
FaxNumber: | 2563811869 | ||||||||
Practice Location | |||||||||
Address1: | 1852 BELTLINE ROAD | ||||||||
Address2: | SUITE A | ||||||||
City: | DECATUR | ||||||||
State: | AL | ||||||||
PostalCode: | 356010000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2563530178 | ||||||||
FaxNumber: | 2563536723 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/02/2007 | ||||||||
LastUpdateDate: | 05/07/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LOVETT | ||||||||
AuthorizedOfficialFirstName: | MARGARET | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 2563813308 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 00025048 | AL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.