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	282N00000X	General Acute Care Hospital

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	510G700322	OTHER		MEDICARE PTAN
5	H565	OTHER		MEDICARE PHYSICIAN PAYEE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	054	OTHER	AL	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891770368
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN MEDICAL CENTER LLC

Provider Business Mailing Address
First Line	:	PO BOX 706
Second Line	:
City	:	EVERGREEN
State	:	AL
Zip	:	36401-0706
Country	:	US
Telephone Number	:	251-578-2480
Fax Number	:	251-578-1055

Provider Business Practice Location Address
First Line	:	101 CRESTVIEW AVE
Second Line	:
City	:	EVERGREEN
State	:	AL
Zip	:	36401-3333
Country	:	US
Telephone Number	:	251-578-2480
Fax Number	:	251-578-1055

Authorized Official
Title or Position	:	CHIEF FINANCIAL OFFICER
Name	:	MRS. SHARON JONES
Credential	:
Telephone Number	:	251-578-2480

Provider Enumeration Date	:	12/07/2005
Last Update Date	:	09/09/2008

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Directions to “EVERGREEN MEDICAL CENTER LLC ” Practice Location

Language	Start Address	Practice Location

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