MEDICARE: EVERGREEN MEDICAL CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician

General Provider Information

NPI Number	:	1356695886
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN MEDICAL CENTER LLC

Provider Business Mailing Address
First Line	:	100 EDWINA STREET
Second Line	:
City	:	EVERGREEN
State	:	AL
Zip	:	36401-3319
Country	:	US
Telephone Number	:	251-578-0278
Fax Number	:	251-578-0290

Provider Business Practice Location Address
First Line	:	100 EDWINA STREET
Second Line	:
City	:	EVERGREEN
State	:	AL
Zip	:	36401-3319
Country	:	US
Telephone Number	:	251-578-0278
Fax Number	:	251-578-0290

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MR. JAMES POWELL
Credential	:
Telephone Number	:	251-578-0278

Provider Enumeration Date	:	11/06/2012
Last Update Date	:	11/06/2012

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Directions to “EVERGREEN MEDICAL CENTER LLC ” Practice Location

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