Provider Demographics
NPI:1871131854
Name:RURAL HEALTH MEDICAL PROGRAM, INC
Entity type:Organization
Organization Name:RURAL HEALTH MEDICAL PROGRAM, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KESHEE
Authorized Official - Middle Name:DANEE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-874-7428
Mailing Address - Street 1:101 PARK PL
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:AL
Mailing Address - Zip Code:36701-6764
Mailing Address - Country:US
Mailing Address - Phone:334-874-7428
Mailing Address - Fax:
Practice Address - Street 1:101 PARK PL
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:AL
Practice Address - Zip Code:36701-6764
Practice Address - Country:US
Practice Address - Phone:334-874-7428
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-20
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL630000008Medicaid