MEDICARE: RUSSELLVILLE HOSPITAL, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician
2	207RC0000X	Cardiovascular Disease Physician

General Provider Information

NPI Number	:	1154332963
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RUSSELLVILLE HOSPITAL, LLC

Provider Business Mailing Address
First Line	:	103 POWELL CT
Second Line	:	STE. 200
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-5079
Country	:	US
Telephone Number	:	615-372-8500
Fax Number	:	615-372-8572

Provider Business Practice Location Address
First Line	:	531 GANDY ST NE
Second Line	:
City	:	RUSSELLVILLE
State	:	AL
Zip	:	35653-1965
Country	:	US
Telephone Number	:	205-485-7280
Fax Number	:	205-485-7391

Authorized Official
Title or Position	:	COO
Name	:	WILLIAM M. GRACEY
Credential	:
Telephone Number	:	615-372-8500

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	09/11/2025

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