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	207R00000X	Internal Medicine Physician	19723	AL
2	207R00000X	Internal Medicine Physician	H1801	AL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	510G700111	OTHER	AL	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891904223
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN MEDICAL CENTER LLC

Provider Business Mailing Address
First Line	:	106 EDWINA ST
Second Line	:
City	:	EVERGREEN
State	:	AL
Zip	:	36401-3319
Country	:	US
Telephone Number	:	251-578-4300
Fax Number	:	251-578-4307

Provider Business Practice Location Address
First Line	:	106 EDWINA ST
Second Line	:
City	:	EVERGREEN
State	:	AL
Zip	:	36401-3319
Country	:	US
Telephone Number	:	251-578-4300
Fax Number	:	251-578-4307

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

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	04/20/2010

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Directions to “EVERGREEN MEDICAL CENTER LLC ” Practice Location

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