=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033202320
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STEVENSON MEDICAL CENTER, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2006
-----------------------------------------------------
Last Update Date | 06/21/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 196 COUNTY ROAD 85
-----------------------------------------------------
City | STEVENSON
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35772-5522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-437-2272
-----------------------------------------------------
Fax | 256-437-2273
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 196 COUNTY ROAD 85
-----------------------------------------------------
City | STEVENSON
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35772-5522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-437-2272
-----------------------------------------------------
Fax | 256-437-2273
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. ALAN J WAYNE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 256-437-2272
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 013785
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------