Basic Information
| Provider Information | |||||||||
| NPI: | 1275795304 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARSHALL MEDICAL CENTER SOUTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2505 US HIGHWAY 431 | ||||||||
| Address2: | |||||||||
| City: | BOAZ | ||||||||
| State: | AL | ||||||||
| PostalCode: | 35957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565938310 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2505 US HIGHWAY 431 | ||||||||
| Address2: | |||||||||
| City: | BOAZ | ||||||||
| State: | AL | ||||||||
| PostalCode: | 35957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565938310 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2008 | ||||||||
| LastUpdateDate: | 06/30/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NELSON | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2568946600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MARSHALL MEICAL CENTER SOUTH | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 200048109 | 05 | AL | MEDICAID |