Provider Demographics
NPI:1174956841
Name:RUSSELLVILLE PHYSICIAN PRACTICES LLC
Entity type:Organization
Organization Name:RUSSELLVILLE PHYSICIAN PRACTICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-565-1898
Mailing Address - Street 1:15225 HIGHWAY 43
Mailing Address - Street 2:SUITE G
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35653-1999
Mailing Address - Country:US
Mailing Address - Phone:256-331-1900
Mailing Address - Fax:256-331-1901
Practice Address - Street 1:15225 HIGHWAY 43
Practice Address - Street 2:SUITE G
Practice Address - City:RUSSELLVILLE
Practice Address - State:AL
Practice Address - Zip Code:35653-1999
Practice Address - Country:US
Practice Address - Phone:256-331-1900
Practice Address - Fax:256-331-1901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-16
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty