Basic Information
| Provider Information | |||||||||
| NPI: | 1346389632 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DALE MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DALE PEDIATRIC CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 863 | ||||||||
| Address2: | |||||||||
| City: | OZARK | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363610863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347938087 | ||||||||
| FaxNumber: | 3347938191 | ||||||||
| Practice Location | |||||||||
| Address1: | 322 WHITE AVE | ||||||||
| Address2: | |||||||||
| City: | OZARK | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363600908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347938087 | ||||||||
| FaxNumber: | 3347938191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2007 | ||||||||
| LastUpdateDate: | 11/06/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MAY | ||||||||
| AuthorizedOfficialFirstName: | REGINA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CONTRACT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3347938087 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DALE MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | CPC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.