Provider Demographics
NPI:1992967772
Name:MARSHALL MEDICAL CENTER SOUTH
Entity type:Organization
Organization Name:MARSHALL MEDICAL CENTER SOUTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:B
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:256-894-6600
Mailing Address - Street 1:2505 US HWY 431 N
Mailing Address - Street 2:
Mailing Address - City:BOAZ
Mailing Address - State:AL
Mailing Address - Zip Code:35957
Mailing Address - Country:US
Mailing Address - Phone:256-593-8310
Mailing Address - Fax:
Practice Address - Street 1:2505 US HWY 431 N
Practice Address - Street 2:
Practice Address - City:BOAZ
Practice Address - State:AL
Practice Address - Zip Code:35957
Practice Address - Country:US
Practice Address - Phone:256-593-8310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARSHALL MEDICAL CENTER SOUTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207P00000X, 207Q00000X, 207R00000X
AL282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No282N00000XHospitalsGeneral Acute Care HospitalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL558200290Medicaid