Healthcare Provider Details

I. General information

NPI: 1033863170
Provider Name (Legal Business Name): MIZELL MEMORIAL HOSPITAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2022
Last Update Date: 02/08/2022
Certification Date: 02/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

918 DRAYTON AVE
ELBA AL
36323-1448
US

IV. Provider business mailing address

PO BOX 1010
OPP AL
36467-1010
US

V. Phone/Fax

Practice location:
  • Phone: 334-493-5713
  • Fax:
Mailing address:
  • Phone: 334-493-5713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JANA WYATT
Title or Position: CFO
Credential:
Phone: 334-493-5790