MEDICARE: EVERGREEN MEDICAL CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WH0200X	Home Health Registered Nurse	10419	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	51043109	OTHER	AL	BC BS

General Provider Information

NPI Number	:	1881677581
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN MEDICAL CENTER LLC

Provider Business Mailing Address
First Line	:	308 SOUTH MAIN ST
Second Line	:
City	:	EVERGREEN
State	:	AL
Zip	:	36401
Country	:	US
Telephone Number	:	251-578-6800
Fax Number	:	251-578-0252

Provider Business Practice Location Address
First Line	:	308 SOUTH MAIN ST
Second Line	:
City	:	EVERGREEN
State	:	AL
Zip	:	36401
Country	:	US
Telephone Number	:	251-578-6800
Fax Number	:	251-578-0252

Authorized Official
Title or Position	:	CFO
Name	:	MRS. SHARON JONES
Credential	:
Telephone Number	:	251-578-2480

Provider Enumeration Date	:	11/28/2005
Last Update Date	:	01/03/2008

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Directions to “EVERGREEN MEDICAL CENTER LLC ” Practice Location

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