Basic Information
| Provider Information | |||||||||
| NPI: | 1548809403 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIZELL MEMORIAL HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | MIZELL MEDICAL CLINIC 2 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1010 | ||||||||
| Address2: | |||||||||
| City: | OPP | ||||||||
| State: | AL | ||||||||
| PostalCode: | 364671010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3344933541 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 103 E MEMORIAL AVE STE A | ||||||||
| Address2: | |||||||||
| City: | OPP | ||||||||
| State: | AL | ||||||||
| PostalCode: | 364671746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3344935555 | ||||||||
| FaxNumber: | 3344930517 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/24/2019 | ||||||||
| LastUpdateDate: | 01/14/2021 | ||||||||
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| AuthorizedOfficialLastName: | WYATT | ||||||||
| AuthorizedOfficialFirstName: | JANA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO / CFO | ||||||||
| AuthorizedOfficialTelephone: | 3344939111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.