Livingston Clinic, Inc.

Contacts

Phone	+1 205-652-2686
Fax	2056527093

Authorized person

Name	DR. WILLIAM RUSS SIMPKINS
Role	PRESIDENT
Phone	2056522686

Taxonomy

Taxonomy Code	208D00000X - General Practice Physician
License Number	5674
State	AL
Is Primary	Yes

Other Provider Identifiers

Issuer	MEDICAID
Number	000005805
State	AL

Three-digit plan number (PN)	001
Effective date of plan	1975-08-01
Business code	621111
Sponsor’s telephone number	2056522686
Plan sponsor’s mailing address	DRAWER T, LIVINGSTON, AL, 354700350
Plan sponsor’s address	DRAWER T, LIVINGSTON, AL, 354700350

Plan administrator’s name and address

Administrator’s EIN	630695337
Plan administrator’s name	LIVINGSTON CLINIC INC
Plan administrator’s address	DRAWER T, LIVINGSTON, AL, 354700350
Administrator’s telephone number	2056522686

Number of participants as of the end of the plan year

Active participants	4
Other retired or separated participants entitled to future benefits	2

Signature of

Role	Plan administrator
Date	2011-01-13
Name of individual signing	WILLIAM R SIMPKINS
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1975-08-01
Business code	621111
Sponsor’s telephone number	2056522686
Plan sponsor’s mailing address	DRAWER T, LIVINGSTON, AL, 354700350
Plan sponsor’s address	DRAWER T, LIVINGSTON, AL, 354700350

Plan administrator’s name and address

Administrator’s EIN	630695337
Plan administrator’s name	LIVINGSTON CLINIC INC
Plan administrator’s address	DRAWER T, LIVINGSTON, AL, 354700350
Administrator’s telephone number	2056522686

Number of participants as of the end of the plan year

Active participants	4
Other retired or separated participants entitled to future benefits	2

Signature of

Role	Plan administrator
Date	2011-01-14
Name of individual signing	WILLIAM R SIMPKINS
Valid signature	Filed with authorized/valid electronic signature