Provider Demographics
NPI:1578195525
Name:RIVER REGION FAMILY MEDICINE, LLC
Entity type:Organization
Organization Name:RIVER REGION FAMILY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:BRUCE
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:256-675-0412
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:WETUMPKA
Mailing Address - State:AL
Mailing Address - Zip Code:36092-0003
Mailing Address - Country:US
Mailing Address - Phone:334-567-4311
Mailing Address - Fax:
Practice Address - Street 1:277 HUNTRESS STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:WETUMPKA
Practice Address - State:AL
Practice Address - Zip Code:36092
Practice Address - Country:US
Practice Address - Phone:334-567-4311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-07
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL120559Medicaid
ALAPPLIEDMedicaid