Provider Demographics
NPI:1003008376
Name:MARSHALL MEDICAL CENTER NORTH JONES PEDIATRIC PRACTICE
Entity Type:Organization
Organization Name:MARSHALL MEDICAL CENTER NORTH JONES PEDIATRIC PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR - PM
Authorized Official - Prefix:
Authorized Official - First Name:VICKY
Authorized Official - Middle Name:R
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-891-3144
Mailing Address - Street 1:227 BRITTANY RD
Mailing Address - Street 2:
Mailing Address - City:GUNTERSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35976-5766
Mailing Address - Country:US
Mailing Address - Phone:256-891-3144
Mailing Address - Fax:256-878-1742
Practice Address - Street 1:45 MEDICAL PARK DR
Practice Address - Street 2:B
Practice Address - City:GUNTERSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35976-5766
Practice Address - Country:US
Practice Address - Phone:256-571-8969
Practice Address - Fax:256-571-8980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-10
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL26482261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL=========OtherTAX ID