Basic Information
| Provider Information | |||||||||
| NPI: | 1013937705 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIZELL MEMORIAL HOSPITAL, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1010 | ||||||||
| Address2: | |||||||||
| City: | OPP | ||||||||
| State: | AL | ||||||||
| PostalCode: | 364671010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3344933541 | ||||||||
| FaxNumber: | 3344933789 | ||||||||
| Practice Location | |||||||||
| Address1: | 702 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | OPP | ||||||||
| State: | AL | ||||||||
| PostalCode: | 364671626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3344933541 | ||||||||
| FaxNumber: | 3344939433 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 12/24/2019 | ||||||||
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| AuthorizedOfficialLastName: | WYATT | ||||||||
| AuthorizedOfficialFirstName: | JANA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3344939111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | 12/24/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QL0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Lithotripsy | 273R00000X | AL | N | Hospital Units | Psychiatric Unit | 275N00000X | AL | N | Hospital Units | Medicare Defined Swing Bed Unit | 282NR1301X | 11789 | AL | Y | Hospitals | General Acute Care Hospital | Rural |
ID Information
| ID | Type | State | Issuer | Description | HOS0007H | 05 | AL | MEDICAID | 010095 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER |