MEDICARE: RUSSELLVILLE PHYSICIAN PRACTICES 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	208600000X	Surgery Physician	17151	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528377983
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RUSSELLVILLE PHYSICIAN PRACTICES LLC

Provider Business Mailing Address
First Line	:	523 GANDY ST NE
Second Line	:	SUITE E
City	:	RUSSELLVILLE
State	:	AL
Zip	:	35653-1961
Country	:	US
Telephone Number	:	256-331-1449
Fax Number	:	256-331-5182

Provider Business Practice Location Address
First Line	:	523 GANDY ST NE
Second Line	:	SUITE E
City	:	RUSSELLVILLE
State	:	AL
Zip	:	35653-1961
Country	:	US
Telephone Number	:	256-331-1449
Fax Number	:	256-331-5182

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. DONALD BIVACCA
Credential	:
Telephone Number	:	615-372-8500

Provider Enumeration Date	:	10/04/2010
Last Update Date	:	10/04/2010

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