Basic Information
| Provider Information | |||||||||
| NPI: | 1871599308 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RUSSELL COUNTY MEDICAL CENTER, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RUSSELL COUNTY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 198250 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303848250 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 58 CARROLL STREET | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2768838000 | ||||||||
| FaxNumber: | 2768894336 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2005 | ||||||||
| LastUpdateDate: | 11/27/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP, COMMUNITY HEALTH SYSTEMS | ||||||||
| AuthorizedOfficialTelephone: | 8883739600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RUSSELL COUNTY MEDICAL CENTER, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 09704001 | VA | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 007676 | 01 | VA | BLUE CROSS | OTHER |