Provider Demographics
NPI:1255669099
Name:SYVERSON MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:SYVERSON MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-424-1200
Mailing Address - Street 1:1400 N MCKENZIE ST
Mailing Address - Street 2:
Mailing Address - City:FOLEY
Mailing Address - State:AL
Mailing Address - Zip Code:36535-2234
Mailing Address - Country:US
Mailing Address - Phone:251-424-1200
Mailing Address - Fax:251-424-1201
Practice Address - Street 1:1400 N MCKENZIE ST
Practice Address - Street 2:
Practice Address - City:FOLEY
Practice Address - State:AL
Practice Address - Zip Code:36535-2234
Practice Address - Country:US
Practice Address - Phone:251-424-1200
Practice Address - Fax:251-424-1201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-04
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty