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	207V00000X	Obstetrics & Gynecology Physician	27647	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	:	1649442369
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RUSSELLVILLE PHYSICIAN PRACTICES LLC

Provider Business Mailing Address
First Line	:	PO BOX 270
Second Line	:
City	:	RUSSELLVILLE
State	:	AL
Zip	:	35653-0270
Country	:	US
Telephone Number	:	256-331-3988
Fax Number	:	256-331-3987

Provider Business Practice Location Address
First Line	:	523 GANDY ST NE
Second Line	:	SUITE F
City	:	RUSSELLVILLE
State	:	AL
Zip	:	35653-1961
Country	:	US
Telephone Number	:	256-331-3988
Fax Number	:	256-331-3987

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

Provider Enumeration Date	:	04/02/2008
Last Update Date	:	06/06/2008

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