Basic Information
| Provider Information | |||||||||
| NPI: | 1598994279 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DALE MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JESSE PEURIFOY JR MD | ||||||||
| 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: | 2126 W ROY PARKER RD | ||||||||
| Address2: | STE 203 | ||||||||
| City: | OZARK | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363608566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347740762 | ||||||||
| FaxNumber: | 3347741348 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2009 | ||||||||
| LastUpdateDate: | 07/02/2009 | ||||||||
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| AuthorizedOfficialLastName: | HULL | ||||||||
| AuthorizedOfficialFirstName: | BRADLEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3347742601 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DALE MEDICAL CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD 24955 | AL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.