Healthcare Provider Details

I. General information

NPI: 1306980412
Provider Name (Legal Business Name): RUSSELL HOSPITAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 04/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3316 HIGHWAY 280
ALEXANDER CITY AL
35010-3369
US

IV. Provider business mailing address

PO BOX 939
ALEXANDER CITY AL
35011-0939
US

V. Phone/Fax

Practice location:
  • Phone: 256-329-7109
  • Fax: 256-329-7617
Mailing address:
  • Phone: 256-329-7109
  • Fax: 256-329-7617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number11873
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier529807150
Identifier TypeMEDICAID
Identifier StateAL
Identifier Issuer
# 2
Identifier558200650
Identifier TypeMEDICAID
Identifier StateAL
Identifier Issuer

VIII. Authorized Official

Name: MR. LOTHER PEACE
Title or Position: PRESIDENT CEO
Credential:
Phone: 256-329-7147