MEDICARE: TRI COUNTY MEDICAL CENTER, INC

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	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1609906395
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRI COUNTY MEDICAL CENTER, INC

Provider Business Mailing Address
First Line	:	PO BOX 726
Second Line	:
City	:	EVERGREEN
State	:	AL
Zip	:	36401-0726
Country	:	US
Telephone Number	:	251-578-1163
Fax Number	:	251-578-6963

Provider Business Practice Location Address
First Line	:	1738 CLEVELAND AVE
Second Line	:
City	:	CASTLEBERRY
State	:	AL
Zip	:	36432
Country	:	US
Telephone Number	:	251-966-5440
Fax Number	:	251-966-5396

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MARILYN J SAWYER
Credential	:
Telephone Number	:	251-578-1163

Provider Enumeration Date	:	03/06/2007
Last Update Date	:	04/07/2008

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