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General NPI Number Information
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NPI Number | 1922234467
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Entity Type | Organization
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Legal Business Name | EVERGREEN BREWTON MEDICAL, INC.
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Dates
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Enumeration Date | 06/10/2009
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Last Update Date | 07/01/2009
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Provider Practice Location Address
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Address Line | 103 ELLIOTT ST
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City | BREWTON
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State | AL
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Zip | 36426-1336
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Country | US
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Telephone | 251-867-8001
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Fax | 251-867-9643
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Provider Business Mailing Address
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Address Line | PO BOX 190
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City | BREWTON
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State | AL
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Zip | 36427-0190
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Country | US
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Telephone | 251-867-8001
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Fax | 251-867-9643
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | CHRIS B GRIFFIN
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Credential |
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Telephone | 251-809-8398
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 13720
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License Number State | AL
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