Basic Information
| Provider Information | |||||||||
| NPI: | 1760728455 | ||||||||
| 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: | 3344939664 | ||||||||
| Practice Location | |||||||||
| Address1: | 802 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | OPP | ||||||||
| State: | AL | ||||||||
| PostalCode: | 364671614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3344933240 | ||||||||
| FaxNumber: | 3344939535 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2012 | ||||||||
| LastUpdateDate: | 01/14/2021 | ||||||||
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| AuthorizedOfficialLastName: | WYATT | ||||||||
| AuthorizedOfficialFirstName: | JANA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3344939111 | ||||||||
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| 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 | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 144655 | 05 | AL | MEDICAID |