Provider Demographics
NPI:1326116880
Name:MARSHALL MEDICAL CENTER SOUTH
Entity Type:Organization
Organization Name:MARSHALL MEDICAL CENTER SOUTH
Other - Org Name:ALBERTVILLE PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:CALHOUN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-894-7795
Mailing Address - Street 1:PO BOX 11407
Mailing Address - Street 2:DEPT #1557
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35246-1557
Mailing Address - Country:US
Mailing Address - Phone:256-894-7795
Mailing Address - Fax:256-894-6471
Practice Address - Street 1:2505 US HWY 431
Practice Address - Street 2:
Practice Address - City:BOAZ
Practice Address - State:AL
Practice Address - Zip Code:35957
Practice Address - Country:US
Practice Address - Phone:256-894-7795
Practice Address - Fax:256-894-6471
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARSHALL MEDICAL CENTER SOUTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-01
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL15304207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALJ340OtherMEDICARE GROUP
ALJ340Medicare PIN
ALJ340OtherMEDICARE GROUP
AL051514931Medicare Oscar/Certification