Individual Professional Information |
|
NPI
|
1649235995
|
|
Unique healthcare provider (clinician) ID assigned by NPPES
|
|
PECOS UID
|
8527008713
|
|
Unique individual clinician ID assigned by PECOS
|
|
Professional Enrollment ID
|
I20091022000534
|
|
Unique ID for the individual professional enrollment that is the source for the data in the observation
|
|
Provider Last Name
|
BEDSOLE
|
|
Individual professional last name
|
|
Provider First Name
|
RUSSELL
|
|
Individual professional first name
|
|
Provider Middle Name
|
LEE
|
|
Individual professional middle name
|
|
Provider Gender
|
M
|
|
The provider's gender if the provider is a person.
|
|
Provider Credential Text
|
MD
|
|
The abbreviations for professional degrees or credentials used or held by the provider, if the provider is an individual. Examples are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations will not be verified by NPS.
|
Practice Information |
|
Organization Legal Name
|
WIREGRASS CLINIC LLC
|
|
Legal name of the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
|
|
Group Practice PAC ID
|
2860662491
|
|
Unique Group Practice ID assigned by PECOS to the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
|
|
Number of Group Practice members
|
32
|
|
Total number of individual professionals affiliated with the Group Practice based on Group Practice PAC ID
|
|
Line 1 Street Address
|
918 DRAYTON AVE
|
|
Group Practice or individual's line 1 address
|
|
City
|
ELBA
|
|
Group Practice or individual's city
|
|
State
|
AL
|
|
Group Practice or individual's state
|
|
Zip Code
|
363231448
|
|
Group Practice or individual's zip code (9 digits when available)
|
|
Phone Number
|
3348530191
|
|
Phone number is listed only when there is a single phone number available for the practice location address
|
Hospital(s) Affiliation Information |
|
Hospital Affiliation CCN 1
|
010055
|
|
Medicare CCN of hospital where individual professional provides service 1
|
|
Hospital Affiliation LBN 1
|
FLOWERS HOSPITAL
|
|
Legal business name of hospital where individual professional provides service 1
|
|
Hospital Affiliation CCN 2
|
010049
|
|
Medicare CCN of hospital where individual professional provides service 2
|
|
Hospital Affiliation LBN 2
|
MEDICAL CENTER ENTERPRISE
|
|
Legal business name of hospital where individual professional provides service 2
|
|
Hospital Affiliation CCN 3
|
010001
|
|
Medicare CCN of hospital where individual professional provides service 3
|
|
Hospital Affiliation LBN 3
|
SOUTHEAST ALABAMA MEDICAL CENTER
|
|
Legal business name of hospital where individual professional provides service 3
|
|
Hospital Affiliation CCN 4
|
010062
|
|
Medicare CCN of hospital where individual professional provides service 4
|
|
Hospital Affiliation LBN 4
|
WIREGRASS MEDICAL CENTER
|
|
Legal business name of hospital where individual professional provides service 4
|
|
Hospital Affiliation CCN 5
|
010007
|
|
Medicare CCN of hospital where individual professional provides service 5
|
|
Hospital Affiliation LBN 5
|
MIZELL MEMORIAL HOSPITAL
|
|
Legal business name of hospital where individual professional provides service 5
|
|
Professional Accepts Medicare Assignment
|
Y
|
|
|