Provider Demographics
NPI:1891770368
Name:EVERGREEN MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:EVERGREEN MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-578-2480
Mailing Address - Street 1:PO BOX 706
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:AL
Mailing Address - Zip Code:36401-0706
Mailing Address - Country:US
Mailing Address - Phone:251-578-2480
Mailing Address - Fax:251-578-1055
Practice Address - Street 1:101 CRESTVIEW AVE
Practice Address - Street 2:
Practice Address - City:EVERGREEN
Practice Address - State:AL
Practice Address - Zip Code:36401-3333
Practice Address - Country:US
Practice Address - Phone:251-578-2480
Practice Address - Fax:251-578-1055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-07
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL054OtherBCBS
ALH0S0148HMedicaid
AL529933017OtherMEDICAID PHYSICIAN PAYEE
510G700322OtherMEDICARE PTAN
H565OtherMEDICARE PHYSICIAN PAYEE
010148Medicare ID - Type Unspecified