Provider Demographics
NPI:1861663874
Name:MARSHALL MEDICAL CENTER SOUTH
Entity Type:Organization
Organization Name:MARSHALL MEDICAL CENTER SOUTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:GORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-593-7266
Mailing Address - Street 1:PO BOX 758
Mailing Address - Street 2:
Mailing Address - City:BOAZ
Mailing Address - State:AL
Mailing Address - Zip Code:35957-0758
Mailing Address - Country:US
Mailing Address - Phone:256-593-8310
Mailing Address - Fax:
Practice Address - Street 1:2505 US HWY 431N
Practice Address - Street 2:
Practice Address - City:BOAZ
Practice Address - State:AL
Practice Address - Zip Code:35957-0758
Practice Address - Country:US
Practice Address - Phone:256-593-8310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARSHALL MEDICAL CENTER SOUTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-18
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL=========001OtherTRICARE