Basic Information
| Provider Information | |||||||||
| NPI: | 1689956500 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RUSSELLVILLE PHYSICIAN PRACTICES LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTH ALABAMA INTERNAL MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1216 | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356531216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563311449 | ||||||||
| FaxNumber: | 2563315829 | ||||||||
| Practice Location | |||||||||
| Address1: | 15225 HIGHWAY 43 | ||||||||
| Address2: | SUITE B | ||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356531999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563311449 | ||||||||
| FaxNumber: | 2563315829 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2011 | ||||||||
| LastUpdateDate: | 06/07/2012 | ||||||||
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| AuthorizedOfficialLastName: | JUDY | ||||||||
| AuthorizedOfficialFirstName: | JESS | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6153728500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 31115 | AL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 132812 | 05 | AL | MEDICAID |