Basic Information
| Provider Information | |||||||||
| NPI: | 1588795942 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IVY CREEK OF ELMORE, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ELMORE COMMUNITY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 130 | ||||||||
| Address2: | |||||||||
| City: | WETUMPKA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 360920003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3345674311 | ||||||||
| FaxNumber: | 3345674312 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | WETUMPKA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 360921625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3345674311 | ||||||||
| FaxNumber: | 3345674312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 04/05/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRUCE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3345674311 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CEO | ||||||||
| NPICertificationDate: | 04/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 11797 | AL | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 010-028 | 01 | BCBS OF ALABAMA | OTHER | 010-028 | 01 | AL | HOSPITAL BCBS OF ALABAMA | OTHER | HOS0097H | 05 | AL | MEDICAID | 01D0680545 | 01 | AL | CLIA | OTHER |