Basic Information
| Provider Information | |||||||||
| NPI: | 1003805870 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RUSSELLVILLE FAMILY CLINIC PA | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1648 | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728111648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4799687170 | ||||||||
| FaxNumber: | 4799687607 | ||||||||
| Practice Location | |||||||||
| Address1: | 108 SKYLINE DR | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728013362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4799687170 | ||||||||
| FaxNumber: | 4799687607 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2005 | ||||||||
| LastUpdateDate: | 03/11/2014 | ||||||||
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| AuthorizedOfficialLastName: | PIKE | ||||||||
| AuthorizedOfficialFirstName: | JOY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4799687170 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 119926002 | 05 | AR | MEDICAID | 8772887600 | 01 | AR | MEDICARE # ISSUED BY GOVERMENT FOR RAILROAD CLAIMS | OTHER |