Healthcare Provider Details

I. General information

NPI: 1285650374
Provider Name (Legal Business Name): RUSSELL COUNTY CLINIC CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 08/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 CARROLL STREET
LEBANON VA
24266
US

IV. Provider business mailing address

7100 COMMERCE WAY SUITE 180
BRENTWOOD TN
37027-2829
US

V. Phone/Fax

Practice location:
  • Phone: 276-883-8470
  • Fax: 276-883-8475
Mailing address:
  • Phone: 866-398-7107
  • Fax: 615-465-3007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DEBBIE T BREWER
Title or Position: DIRECTOR OF PROVIDER ENROLLMENT
Credential:
Phone: 877-892-9813