Provider Demographics
NPI:1104995208
Name:RURAL HEALTH MEDICAL PROGRAM, INC
Entity type:Organization
Organization Name:RURAL HEALTH MEDICAL PROGRAM, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-874-7428
Mailing Address - Street 1:P O BOX 2213
Mailing Address - Street 2:228 SELMA AVENUE
Mailing Address - City:SELMA
Mailing Address - State:AL
Mailing Address - Zip Code:36702-2213
Mailing Address - Country:US
Mailing Address - Phone:334-874-7428
Mailing Address - Fax:334-874-7435
Practice Address - Street 1:558 COUNTY ROAD 56
Practice Address - Street 2:
Practice Address - City:VREDENBURGH
Practice Address - State:AL
Practice Address - Zip Code:36481-0494
Practice Address - Country:US
Practice Address - Phone:334-337-4787
Practice Address - Fax:334-337-4682
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RURAL HEALTH MEDICAL PROGRAM, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-06
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL011890OtherMEDICARE ID - TYPE UNSPECIFIED
AL630000008Medicaid