Basic Information
| Provider Information | |||||||||
| NPI: | 1528377983 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RUSSELLVILLE PHYSICIAN PRACTICES LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | BANKHEAD GENERAL SURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 523 GANDY ST NE | ||||||||
| Address2: | SUITE E | ||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356531961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563311449 | ||||||||
| FaxNumber: | 2563315182 | ||||||||
| Practice Location | |||||||||
| Address1: | 523 GANDY ST NE | ||||||||
| Address2: | SUITE E | ||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356531961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563311449 | ||||||||
| FaxNumber: | 2563315182 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2010 | ||||||||
| LastUpdateDate: | 10/04/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BIVACCA | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6153728500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 17151 | AL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | AL | MEDICAID |