Provider Demographics
NPI:1477032795
Name:MIZELL MEMORIAL HOSPITAL, INC.
Entity Type:Organization
Organization Name:MIZELL MEMORIAL HOSPITAL, INC.
Other - Org Name:MIZELL MEMORIAL HOSPITALIST GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO / CFO
Authorized Official - Prefix:
Authorized Official - First Name:JANA
Authorized Official - Middle Name:
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-493-9111
Mailing Address - Street 1:PO BOX 1010
Mailing Address - Street 2:
Mailing Address - City:OPP
Mailing Address - State:AL
Mailing Address - Zip Code:36467-1010
Mailing Address - Country:US
Mailing Address - Phone:334-493-3541
Mailing Address - Fax:334-493-9664
Practice Address - Street 1:702 N MAIN ST
Practice Address - Street 2:
Practice Address - City:OPP
Practice Address - State:AL
Practice Address - Zip Code:36467-1626
Practice Address - Country:US
Practice Address - Phone:334-493-3541
Practice Address - Fax:334-493-9664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-08
Last Update Date:2019-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty