Healthcare Provider Details

I. General information

NPI: 1477032795
Provider Name (Legal Business Name): MIZELL MEMORIAL HOSPITAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2018
Last Update Date: 12/24/2019
Certification Date: 12/24/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 N MAIN ST
OPP AL
36467-1626
US

IV. Provider business mailing address

PO BOX 1010
OPP AL
36467-1010
US

V. Phone/Fax

Practice location:
  • Phone: 334-493-3541
  • Fax: 334-493-9664
Mailing address:
  • Phone: 334-493-3541
  • Fax: 334-493-9664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: JANA WYATT
Title or Position: CEO / CFO
Credential:
Phone: 334-493-9111