Healthcare Provider Details

I. General information

NPI: 1578645396
Provider Name (Legal Business Name): HAZEL GREEN PRIMARY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13596 HIGHWAY 231 431 N SUITE 4
HAZEL GREEN AL
35750-8617
US

IV. Provider business mailing address

13596 HIGHWAY 231 431 N SUITE 4
HAZEL GREEN AL
35750-8617
US

V. Phone/Fax

Practice location:
  • Phone: 256-829-0610
  • Fax: 256-829-1371
Mailing address:
  • Phone: 256-829-0610
  • Fax: 256-829-1371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number StateAL

VIII. Authorized Official

Name: HEATHER MASON
Title or Position: DIRECTOR OF PHYSICIANS NETWORK
Credential:
Phone: 256-265-7791