Provider Demographics
NPI:1154472397
Name:MARSHALL SURGICAL CLINIC, PC
Entity Type:Organization
Organization Name:MARSHALL SURGICAL CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:CLINK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-593-1611
Mailing Address - Street 1:2525 US HIGHWAY 431
Mailing Address - Street 2:SUITE 170
Mailing Address - City:BOAZ
Mailing Address - State:AL
Mailing Address - Zip Code:35957-5934
Mailing Address - Country:US
Mailing Address - Phone:256-593-1611
Mailing Address - Fax:256-840-4596
Practice Address - Street 1:2525 US HIGHWAY 431
Practice Address - Street 2:SUITE 170
Practice Address - City:BOAZ
Practice Address - State:AL
Practice Address - Zip Code:35957-5934
Practice Address - Country:US
Practice Address - Phone:256-593-1611
Practice Address - Fax:256-840-4596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL528800440Medicaid
AL528800440Medicaid
AL528800440Medicaid