Provider Demographics
NPI:1497893408
Name:DALE MEDICAL CENTER
Entity Type:Organization
Organization Name:DALE MEDICAL CENTER
Other - Org Name:STATMED
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:VERNON
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-774-2601
Mailing Address - Street 1:PO BOX 863
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:AL
Mailing Address - Zip Code:36361-0863
Mailing Address - Country:US
Mailing Address - Phone:334-443-1211
Mailing Address - Fax:334-443-0131
Practice Address - Street 1:1519 ANDREWS AVE
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:AL
Practice Address - Zip Code:36360-3719
Practice Address - Country:US
Practice Address - Phone:334-774-7610
Practice Address - Fax:334-774-7251
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DALE MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-02
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529908700Medicaid
ALH738Medicare PIN
ALCG7907Medicare PIN